Record Release & Letter Request

Please email us at after filling the below form to confirm the submission. Please complete all the information below to start the process for medical record release and letter request. Please do not leave or bring any paperwork or forms or letters to our clinic. Once we receive all the information, we will contact and guide you as needed. Please note that completing below information still require medical release form and we will send it via online patient portal. Please fill all sections below and then click on Submit button at bottom. If there any issues then please use Laptop or Computer. You also can try to use Google Chrome browser on smartphone if needed.