Vermont Natural Family Medicine PLC

I hereby authorize Vermont Natural Family Medicine PLC to release a copy of medical information for: *

First Name

Last Name

Date of birth: *

MM

DD

YYYY

By checking the boxes below, I specifically authorize the release of the following medical records, if such records exist: *

All hospital records

Medical records needed for continuity of care

Most recent five year history

Laboratory reports

Pathology reports

Diagnostic imagine reports

Clinician office chart notes

Physical therapy records

Mental health records

Emergency and urgent care records

Billing statements

Please send the entire medical record

Date *

MM

DD

YYYY