If you would like to have your records transferred to one of these facilities, simply CHECK THE CIRCLE beside your choice BELOW and sign the records release below. Please be sure to include your name, date of signature, date of birth, and the last 4 numbers of your Social Security Number. If you wish to use a different physician or facility, please complete the entire bottom portion of this form-YOU CAN ENTER INFORMATION IN THE 'TEXT AREA BELOW' AND 'PUSH THE SEND MESSAGE' BUTTON. PLEASE CALL 740-587-4300 TO MAKE SURE WE RECEIVED YOUR REQUEST. You may mail this form back to our office at the address listed below; fax to 740-587-4306; or email to drmorris@drmorris.org. We will do our best complete the transfer within 14 days of receiving the signed release form.

ENTER IN BOX ABOVE THE INFORMATION ASKED FOR BELOW I, _______________________________________________(print name) request that a copy of my medical records be released to: PHYSICIAN NAME_______________________________ _______________________________ ADDRESS___________________________ ____________________________________ ______ CITY_____________________________ STATE_____________________ ZIP CODE__________ PATIENT SIGNATURE________________________________ DATE____/_____/____________ BIRTHDATE______/______/_________ SOCIAL SECURITY NUMBER __XXX__-_XX__-______