top of page

mcginleyclinic horizontal logo_edited.png

MAKE AN APPOINTMENT

234 E 1ST STREET, STE 242, CASPER, WY 82601

407 S MEDICAL ARTS CT, STE E2, GILLETTE, WY 82716

PHONE (866) 678-4699 | FAX 833.992.2034

PATIENTS
PHYSICIANS
EDUCATION
- Coming Soon
AR
CONTACT
ABOUT
DIVISIONS
More

Use tab to navigate through the menu items.

Authorization for Release of Medical Records

Patient Name

Date of Birth

Address

Records Requested

Reports

Images

Billing

All

Exam(s) Needed

Date of Exam

Previous Name (if different)

Medical Records # (if known)

Phone

Notes:

I hereby authoize The McGinley Clinic / Elite Imaging Center to release the requested medical rcords to the following facility / physician:

I hereby authoize you to release the requested medical records to The McGinley Clinic / Elite Imaging Center.

Patient or Legally Authorized Representative Signature

Select a date

Printed Name:

Relationship to Patient:

*** We use AMBRA Health Imaging Management and can send imaging electronically to most locations.

*** There is a $25 fee to have your imaging printed and mailed.

Thank you!

The McGinley Clinic

234 E 1ST STREET STE 242, CASPER, WY 82601
407 S MEDICAL ARTS CT, STE E2, GILLETTE, WY 82716
PHONE (866) 678-4699 | FAX 833.992.2034

Subscribe to Our Newsletter!

Thanks for Subscribing!

© 2023 McGinley Clinic, All Rights Reserved

bottom of page