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Medical Release

Fill Out Medical Record Release Form

The first step in this process is to confirm that you have been diagnosed with an eligible condition. Please fill out the medical record release form completely below so that our physician may request a copy of your records. To ensure the form was submitted successfully please scroll back to the top of the form to view confirmation.

If you are not redirected after hitting submit, please scroll to the top of the form to see what fields need to be filled out