Legal Medical Authorization Release Form

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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Records to be released from: Case Medical Center  Ahuja  Bedford  Conneaut  Elyria  Geneva  Geauga  Parma  Richmond  UH Home Care  UHPS  Patient Name (Please Print) Last Date of Birth Address First M/I Social Security Number (last four digits) Phone Number ( )Medical Record Number Prior MR Treatment Date(s) Please Release Medical Information to the Following Recipient: Name of Person or Organization Address City State Zip Code Phone Mailstop Fax Purpose of Disclosure Description of Information to be Released:  Pertinent Summary (includes all items)  Admission Form  Facesheet / Demographics  Physical Therapy  Discharge Summary  Lab Reports  Entire Record  Emergency Room Report  Radiology Report  Physician s Notes  History Physical  EKG Report  Other  Consultation Report  Pathology Report  Operative Report  Card Cath Report  at the patient s request I, the undersigned, authorize (Disclosing Institution) and its employees to release Information from my medical records as described above..

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