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

 

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.