1540 Centennial Ct #300, Casper, WY 82601 • 307.337.4981

Release of Information

I authorize:

Casper General Surgery
Lane L. Smothers, M.D., F.A.C.S.
940 E. 3rd, Suite 215
Casper, WY 82601

Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

All Medical information in the medical records of:

Name of Patient

First Name

Last Name

Birth Date

YYYY

SSN

Signature of Authorizing Party

Relationship to Patient

Witness

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.