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Medical Records Release Form

I, the undersigned, hereby request and authorize AgeWell Rehab Services, PLLC to release my medical records to me via the email address provided below. I confirm that I am the patient requesting this information, and that I have previously made a verbal request for the release of these records.

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Please Select the Medical Record Requested:

Evaluation Report

Treatment Notes

Discharge Report

I acknowledge that the information being released may include sensitive medical information protected under HIPAA and that it will be used solely for the purpose of this request.

By signing below, I consent to the release of my medical records to the email address I have provided on this form.

I consent that by signing below, it will be used as my electronic signature.

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