For your convenience print the 
 medical release form and fax 
 cover sheet below.

 MEDICAL RECORDS RELEASE FORM

 FAX COVER SHEET

 A fee will be charged for all 
 medical record requests of .25¢ per page.

 Copy Fee
 
             ***PLEASE READ SPECIAL NOTICE***

January 26, 2012

Dear Patients,

It is with mixed emotions that I am announcing I will be taking a medical leave of absence effective immediately.  I will provide emergency services for the next 30 days. As of March 1, 2012, I will no longer be seeing patients. 

Your medical records are confidential, and a copy can be transferred to another doctor, to you or to another person you designate only through written permission.  If you have another physician you would like your records transferred to, we will need you to sign a medical release authorization form as soon as possible so we may transfer your records to your new doctor.  

I have greatly valued our relationship. It has been a pleasure providing you your health care  and thank you for your loyalty over the past 17 years.  Best wishes for your future health.

Sincerely,

Christy L. Clayton, MDFACOG

 
Patient's with billing questions, please contact our billing service MBM at 423-629-9783.