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Medical Record Release Authorization

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Macintosh HD:Users:jeremyginman:Downloads: Medical Record Release Authorization copier Staff Initials _____________ Women s Healthcare of Illinois 9730 South Western Ave., Ste. 100 Evergreen Park, IL 60805 Phone (708) 425-1907 FAX (708) 422-4253 9601 W. 165th St., Ste. 2 Orland Park, IL 60467 Phone (708) 349-7310 FAX (708) 349-6916 Medical Records Release Authorization I, ________________________________________ _ hereby authorize Women s Healthcare of Illinois to Release the following information on: Patient name: ______________________________________ Birth date: _______________________ Patient address: ________________________________________ ___________________________________ Phone number: ______________________________ Please check all information to be released.

Macintosh HD:Users:jeremyginman:Downloads:Medical Record Release Authorization 3.29.2012.doc copier Staff Initials Women’s Healthcare of Illinois 9730 South Western Ave., Ste. 100

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