Use this form to request that medical records from another physician or healthcare facility be sent to our practice so that we may have the clinical
information needed to provide you with the most thorough and high quality medical care.
Print out this form to complete. Mail or fax the completed form to your
previous physician or medical facility.
MEDICAL RECORDS RELEASE
Mercer Internal Medicine, LLC
Guy Nee, MD Michael H. Yamane, MD
Mercer Professional Center at Pennington
2480 Pennington Road
Pennington, New Jersey 08534
Tel (609) 818-1000
Fax (609) 818-9800
To (Doctor/Hospital):________________________________________________
I hereby authorize the release of my medical records to Mercer Internal
Medicine, LLC.
Please send the following to the indicated address or fax number above:
___All available records
___Recent EKGs/Labwork
___Hospital history/physical reports and discharge summaries
___Other:____________________
Patient’s name:_____________________________________________________
Patient’s date of birth:__________ Patient’s social security
#:_______________
Patient’s signature:________________________________ Date:_____________ | 
