Please allow up to 10 business days for delivery of records.
If follow-up is required to complete the request, the timeline may be extended.

Please print all 4 pages, complete, and send to:
office@hpwclinic.com or fax to (800)218-6526
*Incomplete requests will not be processed*

To Print:

1.  Click the "Pop-out" icon in the top right corner of the document
2.  Click the "Print" icon in the top menu  bar

You may also pick up a paper copy in our office or have one emailed to you