Authorization for Release of Medical Records
Authorization for Release of Medical Records
This authorization is for the disclosure of health information pertaining to:
Last Name: _____________________________ First: ___________ MI ___
DOB: ______________ Phone Number: ______________
I hereby authorize the disclosure of my health information to:
Stanford University Medical Center
Cardiac Electrophysiology and Arrhythmia Service
c/o Dr. Marco Perez
300 Pasteur Drive #H2146
Stanford, CA 94305
Voice Phone: 650-498-7519
FAX: 650-736-2322
I request that the following information be released at your earliest convenience:
• Clinic Notes
• Dischage Summaries
• Copy of Electrocardiogram
• Results of Echocardiogram
• Results of Holter and Event Monitors
• Results of Chest X-Ray
• Results of laboratory tests
The recipient may use the health information authorized on this form for the conduction of clinical research. The recipient may not lawfully further use or disclose the health information for other purposes.
I may refuse to sign and my refusal will not affect my ability to obtain treatment.
I reserve the right to withdraw or revoke this authorization in writing at any time.
Signature: _________________________________ Date: __________________
If signed by other than patient, indicate relationship: _______________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- medical records release form printable
- authorization to release medical records
- authorization for administration of medicine
- medical records release form
- free medical records release form
- release of medical information form
- medical records release form canada
- usf medical records release form
- certification of medical records letter
- authorization to release medical information
- custodian of medical records form
- blank medical records release form