Medical Records Release Authorization Form
This form will allow patients to authorize copies of their medical information to be released to person/ facility named.
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
