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

All medical information contained in the medical records of:

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. Kevin Helling, Dr. Darren Bowe, and Dr. Brock Anderson of any and all liability relating to such submission of said records.