Michigan Medical Records Release Form 2
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Medical Record Release Form
Date______________________________
I am authorizing the release of my complete medical records from:
Michigan Center for Fertility and Women's Health P.L.C.
Dr. Carole Kowalcyzk
4700 13 Mile Road
Warren, Michigan 48092
Phone: (586) 576-0431
Fax: (586) 576-0924
Please forward my medical records to:
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
By signing this form, I am authorizing the above office to release my complete
medical records to the forwarding medical office.
Patient Name (PRINT)_______________________________________________
Signature__________________________________________________________
Date of Birth_______________ Social Security Number_____________________
I, the spouse of the above patient, request my complete medical records