Colorado Medical Records Release Form 1
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Mark R. Bush, M.D., FACOG, FACS
Michael S. Swanson, M.D., FACOG
Dana Ambler, DO, FACOOG

REQUEST FOR MEDICAL RECORDS &
PERMISSION FOR RELEASE OF INFORMATION
PLEASE SEND THIS REQUEST FORM TO PREVIOUS PHYSICIAN FOR MEDICAL RECORDS
Records Requested from:

Dr. __________________________________________________________
(Address) _____________________________________________________
_______________________________________________________________

____________________________________________________________________________________________
Last name

First name

Middle name

Maiden name

_____________________________________________________________________________________________
Street address

City

State

ZIP

(____)________________________________________________________________________________________
Telephone

Last name under which records may be found (if different)

Please send my records to (check one):
[ ] Send to Littleton Clinic [ ] Send to Lafayette Clinic
271 W County Line Rd
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