1. Ziebler-Niebur Medical Group
1711 West County Road B
Roseville, MN 55113
December 8, 2014
Jane Carlson
546 Highcrest Avenue
Roseville, MN 55113
Dear Ms. Carlson:
Thank you for your request. I am happy to help you with this process. I understand that
you want your medical records sent to Peterson Medical Group. I would love to help you with
accomplishing this goal.
In order to send your records over to Peterson Medical Group, a consent to release form
is required to be filled out. Doing this will help the process move along nicely and will help
protect your medical information. Along with this letter I have enclosed the form as well as a
self addressed envelope. Instructions for filling out the consent to release form can be found
below.
 Fill out the top part of the form until you have filled out the line that states “city, state,
and zip.”
 Check the box that states release information to the following party
 Fill out the lines under it containing information about Peterson Medical Group
 Answer how you would like the forms to be released EX: through the mail
 State why you would like the records to be sent out.
You may also contact medical records directly at 651-555-6785. Thank you again for your
request. We appreciate you greatly. If you have any additional questions feel free to call me at
(651-387-3751) to e-mail me at ellieradams@hotmail.com. We look forward to seeing you soon!
Sincerely
Ellie Adams
Enclosures (2)