Med Records

Patient Authorization For Release

  • Health care facility/Provider

    Who has the information you would like released?
  • Requesting party:

    Inspired Spine
    6600 State Highway 29 S
    Alexandria, MN 56308

    Phone: (727) MY-SPINE
    Fax: (320) 200-7478
  • Authorization

    I authorize the above provider to release the information designated to the requestor.
  • Use your mouse while clicking down to draw in your signature above.