Medical Records Release 2023-11-14

Medical Records Release 1

Records to SFM
Date*

MonthDayYear
Date
To: Medical Records
Name of Physician/Practice to Release Records:*
Physician/Practice Fax Number*
Please enter a valid fax number.Format: (000) 000-0000.
Physician/Practice Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
RE: Patient Name*

First NameMiddle NameLast Name
From: Sparks Family Medicine, Ltd.

410 South Rampart, Suite 390

Las Vegas, NV 89145

Release of Records to:

Sparks Family Medicine, Ltd.

410 South Rampart, Suite 390

Las Vegas, NV 89145

Phone: 702-722-2200

Fax: 702-722-2201
Specific Authorization on Following Page(s)
This message is intended only for the use of the individual(s) or entity to which it is addressed, and may contain information that is privileged, confidential and exempt from disclosure under applicable law. If the reader of this message is not the intended recipient, or the employee or agent responsible for delivering the message.

Medical Records Release 1