Legal Medical Authorization Release Form


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legal Légal health care soins de santé Health Santé medical médical medicine médicament patient government gouvernement law loi authorization autorisation Information Health Sciences Sciences de la santé Understand Comprendre Medical Record Dossier médical

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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