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

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.