Metropolitan Pulmonary, P.C.
Pulmonary and Critical Care Medicine

Release of Medical Records

I request that my medical records be sent from:

______________________________________________________________________________
 ______________________________________________________________________________

To:

Metropolitan Pulmonary, P.C.
290 N.E. Tudor Road
Lee's Summit, MO 64086
Phone: 816-524-5522
Fax: 816-524-4798

Regarding the following diagnosis and dates of service:

______________________________________________________________________________
______________________________________________________________________________

Signature:__________________________________________Date:________________________