Authorization to Release Information

Carriers Concepts, LLC
2147 Buechel Bank Road
Louisville, Ky 40218
P:502-491-5291. F:502-491-5823

Date(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Last Four of Social Security:(Required)

Date of Birth(Required)

I,(Required)

Do Authorize, _______________________ To release information from my Medical Records.
I am requesting, at this time a copy of my Long Form Physical.
I release you from any liability that may be incurred by giving this information to Carriers Concepts, LLC.

Signature(Required)

35875