Authorization For Use / Disclosure Of Health Information

Step 1 of 8

  • Medical Records Request

  • Date Format: YYYY slash MM slash DD
  • To disclose my health information during the term of this Authorization to:

    Pain Relief Solutions
    Casey Fisher, MD
    Zachary Cohen, MD
    3142 Vista way suite 207 Oceanside CA 92056
    Phone: (760) 610-0522 Fax: (760) 610-0523
  • Term: This authorization will remain in effect for one (1) year from the date this authorization is Signed.

  • Date Format: YYYY slash MM slash DD
  • Pain Relief Solutions
    Casey Fisher, MD
    Zachary Cohen, MD
    3142 Vista way suite 207 Oceanside CA 92056
    Phone: (760) 610-0522 Fax: (760) 610-0523