Dr. Kropac Request for Release of Medical Records

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I hereby certify that my medical records be released to:*
I hereby certify that my medical records be released from:*
Medical records needed for the purpose of:*
Date medical records requested:*
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Date medical records needed:*
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Address:
311 Courthouse Rd
Princeton,WV2470

Phone:
(304) 425-9563

NOTICE OF NONDISCRIMINATION:
Orthopedic Center of the Virginias complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Orthopedic Center of the Virginias does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. ATTENTION: If you do not speak English, language assistance services, free of charge are available to you via Fluent Language Services 1-888-306-7726. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. 1-888-306-7726. 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。1-888-306-7726.