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
  Address:
  Attn: Medical Records
  eCounseling Connection, PLLC
  1050 Glenbrook Way, Ste 480-406
  Hendersonville, TN 37075