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Continuation of Care – Release of Information

This form is intended for use by other medical offices and facilities for the purpose of providing information for continuation of care.

This form is NOT for patient use, Legal or Insurance requests for information.
Please complete the information below and click on submit. Your request for medical records will then be sent to the Health Information Management (Medical Records) Department and will be processed.

The requested information will be faxed back to you. If there is a problem with your request, we will contact you by phone.

If this is a STAT request, please submit your information and then call the HIM department at 928-773-2072 to let us know.

Requestor's First Name:*  Last Name:*
Office/Facility:*
City:
State:
Phone Number:*
Fax Number:
Patient's First Name:  Last Name:
Patient Date of Birth:*
Date of Service (at FMC):*
Documents requested:*
Additional Information: