Wallace & Lee Center is dedicated to keeping our patients safe, therefore masks will still need to be worn when inside the office.
I hereby authorize and request that:
Release information from my records to the following:
Please be specific regarding record and dates of Information to be released:
Be advised that if you are requesting a copy of your medical record, a copying fee shall apply. It is prohibited by law to release/disclose the attached/enclosed information to anyone except those specified above. I understand that this Authorization alone may not authorize release of psychiatric or HIV information:
*In signing, I am aware that this authorization is valid for 1 year after today*
