The Pioneer Pelvic Pain Clinic | Albany

Authority to Release Medical Records to Pioneer Health

Please enable JavaScript in your browser to complete this form.

Dear Doctor,

The patient whose details are given below is now attending this clinic for pelvic pain.
I would be grateful if you could forward any relevant medical history / case notes / specialist letters / reports to assist in this patient’s ongoing medical care. If your practice currently uses Best Practice
it would be greatly appreciated if you could forward these notes in .xml format on usb, disc or via Healthlink. Our username is PIONEERH

Could you also please advise us of the most recent dates when any of the following items were
charged:

Thank you for your assistance.

Yours faithfully,
Pioneer Health Albany

Agreement