Medical Record Release Form- To Stark Medical

Medical Record Release Form

*Please use this form if you are requesting an outside person/organization release your records to Stark Medical.*
Patient Information
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@gmail.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person/ Organization to RELEASE Information
Organization Name/ Provider Name
Phone Number
Format: (000) 000-0000.
Fax Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person/Organization to RECEIVE Information
STARK MEDICAL

Brandan Stark DO

Yvette Stark NP

PH: 530-514-0904

FAX: 866-493-2923

PO BOX 2802

BELLINGHAM, WA 98227

Medical Record Release Form