Medical Records Release
VS Primo HealthCare
— V. Sciortino, M.D.
Patient Info
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Patient Information
First name
Last name
Date of birth
Month
Day
Year
Email
Phone
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Records Recipient
Send records to
Healthcare Provider
Other Contact
Healthcare Provider Details
Provider / facility name
Fax number
Location / address
Phone number
Other Contact Details
Contact name
Phone number
Fax number
Email
Mailing address
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Upload Signed Release
Upload signed release form (PDF)
Signed PDF only (up to 10 files, max 10MB each) — this document authorizes the release of your medical records
I confirm that I am authorized to communicate regarding the HIPAA-protected information in this request and that the uploaded release form has been signed by the patient or authorized representative.
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