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