Medical Records Release Authorization Form

If you would like your medical record released to yourself or another facility, please send the completed authorization to the address listed below. You may also request your records through your MyChart account.

Please send completed form to:

Reliant Medical Group
385 Grove Street, Worcester, MA 01605
(508) 721-1142 • Fax: (508) 453-8030
Email: release@reliantmedicalgroup.org

If you are a brand new patient to Reliant Medical Group and need to have records from your previous provider sent to Reliant Medical Group,  please complete the authorization and send it to your former healthcare provider (s) so that your records may be sent to us.