Authorization Of Records Release

Click here to download a PDF of our Authorization Of Records Release or fill out the online form below.

  • AUTHORIZATION OF RECORDS RELEASE

    **GOVERNMENT ISSUED PHOTO ID REQUIRED TO MATCH SIGNATURE BEFORE RECORDS CAN BE RELEASED (You will need to attach a copy of a government issued photo ID using the file uploader below)
  • MM slash DD slash YYYY
  • Name of Health Care Provider/Plan/Other
  • Fox Valley Pulmonary Medicine SC
    2500 Capitol Drive
    Suite 2600
    Appleton, WI 54911
  • Name of Health Care Provider/Plan/Other
  • Digital Signature & Date

    I certify that this request has been made freely, voluntarily and without coercion and that the information given above is accurate and complete to the best of my knowledge. I may revoke this authorization in writing, at any time except to the extent that action has already been taken to comply with it. Any disclosure of information carries with it the potential for unauthorized redisclosure, and the information may not be protected by federal confidentiality rules.
  • MM slash DD slash YYYY
  • Accepted file types: jpg, jpeg, gif, png, pdf, Max. file size: 5 MB.
    Files accepted: JPG, JPEG, GIF, PNG, PDF