Request Records by Authorization Form

Download authorization form as printable PDF

Release of records requires patient/legal guardian authorization. The steps to release medical records are below.

  • Download the authorization form.
  • Complete the authorization form.
  • Fax or mail the completed form to the number or address listed below.
    Secure Medical Fax Line. 615-645-4774
    Attn: Medical Records
    eCounseling Connection, PLLC
    1050 Glenbrook Way, Ste 480-406
    Hendersonville, TN 37075