Home / Services / Diagnosis Letter Get A Diagnosis Letter in minutes Your browser must support JavaScript in order to schedule an appointment. Schedule Details Full Name * Email * Phone Number * Please remove dashes from the phone number entered. Address * What was your original diagnosis? * Medical Records Release Form By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/person/facility/entity listed below. Patient Name * The information you may release subject to this signed release form is as follows: Complete Records Care Plan Pathology Reports Hospital Reports History & Physical Lab Reports Treatment Record Medication Record Progress Notes Radiology Reports Operative Reports Other (Please Specify) Release of Health Information Release my protected health information to the following physician/person/facility/entity and/or those directly associated in my medical care: Name * Address: * Signature (Type Full Name) * I accept the terms & conditions Choose... Month / Day / Year Choose a date above to see available time slots. : : Book Now CLOSE Category: Services Related products Missouri Medical Card – 10 Minute Appointment $119.00 10 minutes Book Lost Card Replacement $20.00 10 minutes Book
