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Ziegler-Niebur Medical Group
1711 West County Road B
Roseville, MN 55113
December 12, 2014
Jane Carlson
546 Highcrest Avenue
Roseville, MN 55113
Dear Ms. Carlson:
Thank you for your request. I am very pleased to help you. In order for me to send your records
to Peterson Medical Group, I need you to complete and sign a consent form.
A complete medical release form is very critical when handling your private records. This will
ensure your records to be secure. The consent form is enclosed with a self-addressed, stamped
envelope, and the form will be delivered directly to the clinic.
Sending the form back to the clinic will help expedite the transfer, so you’re able to get the
medical help you need. The process will take two to three weeks.
Considering the importance of details in this form, I’d like to help you complete it accurately.
Filling it out completely will minimize delays in the process. These are instructions for
completing the form:
 On the top portion, fill in all of your information completely.
 Below that, check “release information to the following party”
 Next to “name”, fill in “Peterson Medical Group”
 For the following portion, record all of Peterson Medical Group’s information.
 Complete the section below (records to be released and why).
 Make sure to read, and sign the bottom where it says “Signature of Client”
 Have a witness (family member or close friend) sign where it says “signature of witness”
Once again, thank you for taking your time to send me your request. I’m more than pleased to
help you. If you have any questions at all, be sure to call me at 619-623-1300. I am looking
forward to hearing from you.
Sincerely,
Iran Madow
Medical Assistant
Enclosure (2)