Please send request to: stanford hospital and clinics health information management services 450 broadway, pav-c, room c14, mc5200 redwood city, ca 94063 phone: 650-723-5721 fax 650-725-9821 stanford hospital and clinics (shc) lucile packard...
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16020 park valley drive * round rock, tx 78681 4112 links lane ste. 101 *round rock, tx 78664 345 cypress creek drive ste. * cedar park, tx 78613 12176 n. mopac expressway ste. d * austin tx, 78758 phone 512-244-0766 * fax 512-244-1013 *...
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Authorization for release of medical information patient name: (please print) last first m/i date of birth: social security number (last four digits): address: phone number: ( ) - medical record number: please release medical information to the...
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Authorization to release medical information please release my records: to: from: central oregon dermatology 388 sw bluff drive bend, or 97701 telephone (541)678-0020 fax (541)323-2174 from: to: mail fax: ( ) fax number please only records...
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Medical record number: (for internal purposes) authorization for the release of protected health information health information management department patient name: last 4 digits of ssn: previous name, if applicable: address: city: state: zip code:...
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Name: uo id: authorization for release of and/or verbal exchange of confidential medical information dob: i hereby consent and authorize the university health center to: send a copy of my specific health information to person or entity named below...
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Authorization to release medical information by: david w. kossoff, m.d. 1. i authorize: david w. kossoff, m.d. 56 thomas johnson drive suite 110 frederick, maryland 21702 phone: 301-624-5566 fax: 301-624-5542 2. release to: name of sending person/...
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Chicago regional council of carpenters welfare fund 12 east erie street chicago, il 60611 312?787?9455, phone option #3 instructions for completing an authorization for release of protected health information 1. complete the authorization for...
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Return this form to release of information roi at the south office 6640 sw redwood lane, portland or 97224 or fax to 503-620-5348 authorization to release medical information from the portland clinic patient name dob former name current address...
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Static barcode 321 2-hole 1/4 2 3/4 - 3-hole 1/4 4 1/4 authorization to release medical information (not for psychotherapy notes) patient name social security # date of birth maiden/other name patient address street city state zip phone number i...
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Authorization to release medical information and/or medical records patient name: date of birth (please print) i authorize (?the clinic?) to use or disclose protected health information (?phi?) contained in my medical records in the following...
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Authorization to release medical information familyhealth medical clinics patient s name: date of birth: this will authorize: familyhealth medical clinic - farmington 4645 knutsen drive, farmington, mn 55024-8455 phone: (651) 460-2300 fax: (651)...
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Neurology medical records /columbia university medical center 710 west 168th street new york, ny 10032/ t(212) 212-342-4517; f(212)342-4536 .columbianeurology.org form revised: january 18, 2013 authorization to release medical information patient...
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Authorization to release medical informationi authorize the named health care provider to release the information or records specified tonorth carolina league of municipalities upon request in person or by mail to the addressspecified at the time of
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Authorization to release medical information where to send/release information: release records to: childrens eye care 11013 hefner pointe dr. oklahoma city, ok 73120 patient identification printed name: date of birth: telephone: address:...
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