Records Release Form

Please complete the form below and visit our shop page to select your preferred delivery method for your records. Thank you.

Name

First Name

Last Name

Phone

(###)

###

####

Release of Records

I understand that certain information in my records cannot be released without specific authorization due to federal or state laws. By signing below, I specifically authorize Balanced Rock Wellness to release my confidential medical records using my chosen method of delivery as indicated below.

Release Instructions - Please Release my Records Accordingly

Email address entered below - $6.50

Aspire MD, Dr. Kim Maroney - $6.50

Third Party Release via Electronic Delivery - $6.50

Third Party Release via Mail - $25.00

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Fax

(###)

###

####

By selecting I acknowledge below, I am authorizing Balanced Rock Wellness to release my medical records according to the instructions specified above.

Please visit the shop to purchase your record delivery method.