The GW Medical Faculty Associates - Hospitals, Urgent Care ...
[Pages:1]The Fac
AUTHORIZATION FOR RELEASE OF INFORMATION
Patient Name: DOB:
MRN:
I authorize Adventist HealthCare Imaging to release information from my medical record.
q Self
q Mail as Specified
q Fax as Specified
Name: Address:
City: State:Zip Code:
Phone:Fax:
Attention (Required):
Information to be released:
Medical reports for the following dates:
to
Medical reports related to the following condition and treatment:
If a patient is a minor, incompetent or unable to give consent, please complete.
I certify that the above patient is unable to give consent because:
and that I am authorized to consent for him/her.
Signature:Date: Printed Name: PSS:Date:
Please call 301-590-8999 for information on how to return completed form.
................
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