Medical Records Release — VS Primo HealthCare

First name

Last name

Date of birth

Email Phone

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

Upload signed release form (PDF) Signed PDF only — 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.