ALLIED BEHAVIORAL CONSULTANTS

Medical Record Form

ABC                Allied Behavioral Consultants


Please release my medical records excerpt from Allied Behavioral Consultants to my new provider:



Patient name: _________________________________


Patient birthdate ________________ (MM/DD/YYYY)




New Provider Name: __________________________


New Provider Address: __________________________

_________________________

City_____________________

State__________Zip_______




Enclosed is my check to 'Karen Wood, administrator' for handling fee $25.25 plus retrieval fee $23.88 ($49.13 total) as outlined in Missouri Statutes (HB 351)





Patient signature ____________________________Date__________


Website Builder