I, * (please enter full name), authorize ICAM Institute of Amarillo, LLC to release any and all medical records to myself via fax, email, or mail. I realize that any fax or email may be sent unencrypted. I also authorize the following person(s) to request this information on my behalf, as well as discuss patient medical records.
This authorization is in force 12 months from the date listen above.
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I, * (please enter full name), request that patient medical records only be released upon my request via my physical presence in the office of ICAM Institue of Amarillo, LLC.