605-339-1872
Toggle Navigation
Home
About SSI
A pioneer in sinus relief
Education that never ends
Teaching the experts
The FIERO award
Acclaimed publications
Sinus Breakthroughs
The power behind an idea
Small holes can solve big problems
Preserve much, invade little
A deeper Look at anatomy
Sinus Education
Getting to know your sinuses
Sinus terminology & definitions
How the sinuses work
What causes sinus problems
The definition of a sinus problem
Paperwork
HIPAA
Request your records
Contact Information
Contact Us
Medical Records Request
Patient Name:
DOB:
What you would like sent:
Please check each item to be released
Physicians Notes
Lab Results
CT Scan
Operative Report
All Medical Records (including CT Scan)
Where and how you would like them sent:
Name:
How you would like them sent:
Mailed
Pick Up
Email
Faxed
Address if mailed:
PO Box:
City:
State:
Choose a state
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
Email address, if emailed:
Fax number, if faxed:
Date of upcoming appointment:
Date:
12/21/2024
Sign your name:
Clear
I,
authorize Setliff Sinus Institute to disclose medical information to
Relationship to patient:
Type your name:
Prove you are human:
Choose the
person
Choose the
envelope
