Authorization for Release of Medical Records

Completion of this form grants the release of your records to:
Christian Family Medicine and Pediatrics

This consent is valid for 90 days. It may be revoked by the signer at any time.
This release is not valid retroactively.

Patient Information
Release Information
  • Please allow 15 days for processing.
  • Incomplete information will delay processing.
  • Use of this information for any other than the stated purpose is prohibited.
  • This information is for the use of the designated recipient only and cannot be provided to any other agency.