medical-release

Medical Records Release Form

In order to ensure that your medical records are held in the utmost confidentiality please complete form in its entirety so that we may obtain proper records.

Name

DOB

Adress

Phone Number

Please transfer my medical records:

To/From

To/From:
Mark Bouffard, M.D.
72650 Fred Waring Drive #214,
Palm Desert, CA 92260

Please specify which records you want released:

I understand that my Medical Records are protected under State and Federal Confidentiality regulations and will be obtained for office use only.

By submitting this form, I am consenting that the information contained in this form is correct and submission of the form represents my electronic signature of the information above