Release of Information

I authorize:

Address
Address
TO RELEASE All Medical information in the medical records of:
Name of Patient
Name of Patient
Birth Date
Birth Date

TO:
CASPER GENERAL SURGERY
Lane L. Smothers, M.D., F.A.C.S.

940 E. 3rd, Suite 215
Casper, WY 82601


A copy is as valid as an original. I understand that you may transmit my medical records either electronically or via the US Mail, and I authorize you to do so. If they are recieved by another party in error, I absolve Dr. Lane Smothers and Casper General Surgery of any and all liability relating to such submissions of said records.