Fillable RELEASE OF RECORDS I hereby authorize: Desert Perinatal

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RELEASE OF RECORDS I hereby authorize: Desert Perinatal

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RELEASE OF RECORDS
I hereby authorize: Desert Perinatal Associates
5761 S. Fort Apache Road
Las Vegas, Nevada 89148
To release my medical records to:
___________________________________
___________________________________
___________________________________
Information contained in the medical records of:
Patient’s Name: ___________________________________
Date of Birth: ____/____/____ SS#: _____________
I understand that I may revoke the authorization at any time except to the
extent that action has been taken in reliance on it and that in any event this
authorization automatically expires 90 days from the date of my signature or
as otherwise specified by date, event or condition as follows.
___________________________________ ___________________
Patient’s Signature Date
Comments: ________________________________________________
__________________________________________________________
Southwest Location: 5761 S. Ft. Apache • Las Vegas, Nevada 89148
Summerlin Location: 10105 Banburry Cross, #430 • Las Vegas, Nevada 89144
Green Valley Location: 3001 Horizon Ridge Parkway • Henderson, Nevada 89052
Phone: (702) 341-6610 • Fax: (702) 341-6961 • www.DesertPerinatalAssociates.com
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RELEASE OF RECORDS I hereby authorize: Desert Perinatal

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Completed 1 December 2020

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