I hereby request that my Umass-Memorial Health Care medical records be released to Dr. Henry DeGroot, at his office at 332 Washington Street, Suite 275, Wellesley Hills, MA 02481

Signed: _____________________________________ Date: ___________

Print Name _____________________________________

Mailing address _____________________________________________________________

_____________________________________________________________

Phone number____________________________________________

e-mail address ___________________________________________

Social security number ____________________________________

UMASS medical record number (if you have it)_______________________________

Mail to: Patti Davis
Department of Orthopedics
UMass-Memorial Medical Center University Campus
55 Lake Avenue North
Worcester, MA 01655