Record Release Authorization

RECORD RELEASE AUTHORIZATION

DOCTOR/HOSPITAL____________________________________________________

ADDRESS______________________________________________________________

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I HEREBY AUTHORIZE AND REQUEST THE RELEASE OF MY MEDICAL RECORDS TO:

Millennium Health & Wellness

Las Cruces, NM88011

PH:  (505)521-0793

FAX:  (505)532-1607

THANK YOU IN ADVANCE FOR YOUR COOPERATION.

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Patient’s Signature                                                                                   Date

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Patient’s Name (Please Print)

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Signature of Parent/Guardian if a Minor                                          Relationship

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Witness To The Above Signatures                                                             Please Print Name