Medical Records Forms
You may print the form below and complete by hand. The completed form may then be mailed, faxed or hand delivered to our medical records department for submission.
Please include valid picture ID copy with your form submission.
Medical Records Release Form
For fax and mail submissions please include ATTN: Medical Records
117 Camino de Vida, Suite 100
Santa Rosa, NM 88435
Phone: (575) 472-3417
Fax: (575) 472-4587