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Patient’s Name Birth date (Please Print) LAST FIRST MI Are medical records filed under another name Phone Number INFORMATION TO BE RELEASED BY: INFORMATION TO BE RELEASED TO: REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER REQUEST MUST HAVE COMPLETE ADDRESS OR FAX NUMBER Organization/Person Name Organization/Person Name Street Address Street Address City, State, Zip City, State, Zip Phone Phone Fax Fax TYPE OF MEDICAL INFORMATION REQUESTED: Complete medical record abstract (includes 3 years of chart notes, most recent labs/pathology diagnostic imaging reports) Cancer Partnership records Radiology/ Diagnostic Imaging (CD/Films) Mammogram Diagnostic Imaging (CD/Films) Echocardiograms Pharmacy Behavioral Health records only My health information relating only to the following treatment or condition: My health information only for the following date(s): Other: REASON FOR REQUEST: Personal Transfer of Care Disability Insurance Legal Review Continuing Care Other (please explain): I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV)..
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