Release of Information to Wyoming Surgical Associates

I AUTHORIZE THE PERSON INDICATED BELOW TO RELEASE INFORMATION TO:
Wyoming Surgical Associates, P.C.
James A. Anderson, MD
Todd H. Beckstead, MD
Robert C. Ratcliff, MD
Brock A. Anderson, MD
419 S. Washington, Suite 200
Casper, WY 82601

 

Patient:
SSN#:
Relationship to Patient:
Signature of Authorizing Party:
Witness Signature:
Please enter your name here to indicate that you have read the following statement:

A copy is as valid as an original. I understand that you may transmit my medical records either electronically or via the US Mail, and I authorize you to do so. If they are received by another party in error, I absolve Dr. James Anderson, Dr. Todd Beckstead, Dr. Lane Smothers, Dr. Robert Ratcliff and Dr. Brock Anderson of any and all liability relating to such submission of said records.