Electronic Consent for Release of Information

Please use this electronic fillable form for any request you may have of FCA staff to release any part of your healthcare record to another individual, organization or provider. Complete and sign the form, using your electronic signature, and we will arrange for the appropriate records to be sent. Use the following form to clarify for our administrative staff the particular document(s) you would like to have sent, as well as any other relevant information regarding your request.

Auto Reply
Thank you for your recent enquiry. Someone will get back to you as soon as possible.

Signature (Supports HTML)
Kind Regards
The Team

Please Complete the Following Form and Sign