• How can we help you today?*
  • Who is this request for?*
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Date of Birth*
     - -
  • Which Amberwell Lansing Clinic provider(s) are you interested in seeing?
  • Do you have any specific care needs? (choose one or more)
  • Would you like to authorize Amberwell to request a copy of your patient records from your previous provider?*

  • Medical Records Release Authorization

  • Pease complete the form below to provide the authorization for Amberwell Health to obtain your medical records from your previous provider.

  • Date
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Purpose of disclosure (select one)*
  • What level of records access are you authorizing?*
  • What specific records are you authorizing?*
  • What date range are you authorizing?*

  • Please indicate the date range you are authorizing:

  • From*
     - -
  • To*
     - -
  • Browse Files
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    Choose a file
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  • Expiration date (if desired)
     - -
  • Should be Empty: