(682) 323-8899

info@pcec247.com

Contact Us

Request PrimeCare to Release Your Records

Authorize PrimeCare Emergency Center to send your medical records to you, a family member, another healthcare provider, or an insurance company.

First Name

Last Name

Email address

Date of Birth

Social Security Number

Phone number

I hereby authorize the release of information concerning my treatment from:

Facility Name

Street Address

Apartment/Suite/Unit

City

State/Province

ZIP/Postal Code

Phone number

Fax

Information Requested:

Or Other (Specify)

You have the right to revoke this authorization at any time by submitting a written revocation to PrimeCare Emergency Center’s Medical Records Department. Revocation does not apply to information already released in response to this authorization.

Signature