Missouri Medical Record Release Authorization
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Briarcliff Medical Associates, P.C.
5400 North Oak Trwy., Suite 200
Kansas City, MO 64118
Phone: 816-453-0900 Fax: 816-453-6271

Medical Record Release Authorization

Patient Name_____________________________________Maiden Name________________SS#_____________
Date of Birth________________________Home Phone____________________Cell/Work__________________
Address___________________________________________City/State/Zip______________________________
Email Address: _______________________________________________________________________________
I hereby Authorize:

To send the following information to:

Name__________________________________________

Name__________________________________________

Address________________________________________

Address________________________________________

City/State/Zip____________________________________

City/State/Zip____________________________________

Phone#__________________Fax#___________________

Phone#__________________Fax#___________________