Medical Record Release | Internal Medicine and Pediatrics of Cullman, P.C.

Name of Requestor and Relationship to the Patient(Required)

Name of Provider or Facility(Required)

Phone Number(Required)

Fax Number(Required)

Type of Records Requested(Required)

Please Describe

This authorization will automatically expire one (1) year from the date submitted. I understand that I may revoke this consent at any time except to the extent that action has been taken in reliance thereon.

I understand that:

My right to healthcare treatment is not conditioned on this authorization
I may cancel this authorization at any time by submitting a written request to the address: 1890 AL HWY 157, Suite 430 Cullman, AL 35058, except where a disclosure has already been made in reliance on my prior authorization.
My information can be released by verbal communication, mail, fax, or email.

Driver's License Upload(Required)

Max. file size: 50 MB.

To verify your identity, you must upload a picture of the front of your driver’s license for review.