Please fill out the Authorization for Use or Disclosure of Protected Health Information form correctly and entirely. An invalid release/incomplete form will delay the process. Evolve Restorative Center legally has 15 days to complete your request. This begins once the medical record department receives the request and the form is completed correctly. Please make sure to sign, date and check all necessary boxes.
Please return the completed form one of the following ways:
Mail to 220 Concourse Boulevard, Santa Rosa, CA 95403
Email to amendez@evolverestorativecenter.com
Fax to 844-847-4943 Attn Medical Records
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