Menu Therapy Options Land Physical Therapy Aquatic Physical Therapy AcupunctureLocationsTestimonialsForms/FormasContact Us Coronavirus Update Make an Appointment Menu Therapy Options Land Physical Therapy Aquatic Physical Therapy AcupunctureLocationsTestimonialsForms/FormasContact Us Coronavirus Update LYG Medical Records Release Request I authorized LYG, A Medical Corporation, to use and disclose the protected health information described below to:Name of Healthcare Provider/Physician/Facility/Medicare Contractor (Nombre del Proveedor de Atención Médica / Médico / Centro / Contratista de Medicare)Address of Healthcare Provider/Dirección del Proveedor de Atención Médica Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Name/Nombre del Paciente First Last Patient Phone/Teléfono del PacientePatient Email Patient Date of Birth/Fecha de Nacimiento del Paciente Date Format: MM slash DD slash YYYY This authorization for release of information covers the period of healthcare from the date of the signature or on:Specific Date Date Format: MM slash DD slash YYYY I authorize the release of my complete health record with the exception of the following information:Autorizo la divulgación de mi registro de salud completo con la excepción de la siguiente información:Medical Records to be released/Registros Médicos que se Publicarán Mental Health Records/Registros de Salud Mental Communicable Diseases (including HIV and AIDS)/Enfermedades transmisibles (incluido el VIH y el SIDA) Alcohol/Drug Abuse Treatment/Tratamiento de Abuso de Alcohol / Drogas Other (please specify)/Otro (por favor especifique) Other Records to Release are/Otros Registros para Publicar sonToday's Date/Fecha Date Format: MM slash DD slash YYYY Representative Name (only if applicable)/Nombre del Representante (Solo si Corresponde) First Last MAIN OFFICE 1809 E. Dyer Rd. #313 Santa Ana CA 92705 Fax (949) 975-0070 No Referral Needed Make an Appointment MAIN OFFICE 1809 E. Dyer Rd. #313 Santa Ana CA 92705