Complete and return to:
Kemberton Records Mgmt.
109 West Park Drive, Ste. 340
Brentwood, TN 37027
Phone: 615-846-7147
Fax: 615-777-5620
AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
Patient Information:
Release Records To: (Where do you want the records to be sent?)
Method of Sending:
Information to be disclosed:
We will NOT include records that contain information about the conditions below unless checked.
Revocation:
Additional Information:
If patient is unable to sign, please specify why: