I hereby authorize the release of my medical records held by:

Note: Upon disclosure of this information, it may be subject to re-disclose by the recipient, and is no longer protected under law. We will provide your medical records to another physician as a professional courtesy.

Note: Upon disclosure of this information, it may be subject to re-disclose by the recipient, and is no longer protected under law. We will provide your medical records to another physician as a professional courtesy.