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
Lane L. Smothers, MD
Robert C. Ratcliff, MD
Brock A. Anderson, MD
419 S. Washington, Suite 102
Casper, WY 82601

Name: *

Address: *

City: *

State: *

Zipcode: *

All medical information contained in the medical records of: * Patient:

Birth date: *

SSN#:

Relationship to Patient:

Signature of Authorizing Party:

Date: *

Witness Signature:

Witness_date:

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.

Important Updates

We will be closing for Memorial day at noon on Friday May 25 and will return on Tuesday May 29

Our doctors will be in this office location during the following listed times:

Dr. James Anderson

Is in the Casper office all day Monday and Wednesday mornings

Will be in Riverton and Thermopolis on March 23 and May 18

Will be in Gillette and Buffalo on April 27 and June 15

Dr. Todd Beckstead

Is in the Casper office all day Tuesday and Thursday mornings

Will be in Riverton on April 6 and June 1

Will be in Rawlins on May 4

Dr. Lane Smothers

Tuesday morning and all day Thursday

Dr. Robert Ratcliff

Tuesday and Wednesday afternoons

Dr. Brock Anderson

Monday and Wednesday mornings