605-339-1872
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Medical Records Release
Patient Name:
DOB:
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Physicians Notes
Lab Results
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All Medical Records (including CT Scan)
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Substance Abuse (including alcohol/drug abuse)
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No
Psychiatric/Mental Health treatment records. (Note: Release of Psychotherapy Notes requires a separate authorization and will not be included in this release.)
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HIV related information (AIDS related testing)
Who is sending the information:
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Where you like them sent:
Sioux Falls
Setliff Sinus Institute
2709 East 26th Street
Sioux Falls, SD 57103
Phone: 605-339-1872
Fax: 605-339-3872
Date of upcoming appointment:
Date:
04/18/2024
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