The GW Medical Faculty Associates - Hospitals, Urgent Care ...

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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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