Release of Medical Information - FROM Dr. Wagner

If you want Dr. Wagner to release your medical records to another provider, click below to print the release form...

All information is required in order for our office to release records to another Provider.
Instructions - Provide the following information:
- Patient Name and Date of Birth
- The name, address, phone# and/or fax# of the Provider you want your records released to.
- Check the box of each record that you want released. Provide the date or date range for each item checked.
- Sign and date at the bottom. If you are not the patient, provide your relationship.

To submit your request:
1. Return this completed form to us. We will forward the requested records to the Provider that you listed.

 

Copyright © 2017 Laura Wagner, MD. All Rights Reserved.
14377 Woodlake Dr. #111 • Chesterfield, MO 63017
314-434-1111