For a patient’s medical records to be released from this facility, the patient must contact the Orthopaedic and Sports Medicine Center’s Medical Records Department for a separate Authorization to Release Medical Information.

Permission
Permission to Share Your Orthopaedic and Sports Medicine Center Medical Information
Sharing
Other than myself, my medical information (including, but not limited to, office exam notes, lab results, billing info, etc.) may be shared with:
Please list name and relationship
Please list name and relationship
Digital Signature
I attest that the above information is correct and to the best of my knowledge. I have read and understand the entire contents of the form and have had the opportunity to ask questions regarding the information of this form.