Authorization to Release Records and X-rays
Each adult patient must sign his/her own Authorization to Release form
Dr. Randy Otterholt
6817 N. Cedar Road, Suite 102
Spokane, WA 99208
(509) 327-4469
fax (509) 328-9902
Authorized to release records and x-rays to:
Doctor: ______________________________________
Address: ______________________________________
______________________________________
______________________________________
Patient Information:
Your name: ______________________________________
Address: ______________________________________
______________________________________
______________________________________
______________________________________
Patient Signature
_______________________
Date
