• Consent for Release of Medical Records

  • Please indicate your doctor’s contact info so we can obtain your medical records. If you are a former patient of Dr. Mintz, you may leave this blank, as we have the information on file. 

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  • I am presently a patient of Dr. Matthew Mintz in Bethesda, Maryland and do hereby authorize the release of my medical records

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  • Please address correspondence to:                          
     
                                          Dr. Matthew Mintz
                                          6000 Executive Blvd
                                          Suite 315
                                          Rockville, MD 20852
                                          Phone and Fax 1-855-646-8963
     
     
    * This authorization is valid for 90 days from the date of signature.
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