Transcription of AUTHORIZATION FOR RELEASE OF INFORMATION
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AUTHORIZATION FOR RELEASE OF INFORMATION
AUTHORIZATION FOR RELEASE OF INFORMATION Records to be released from: HOLD FOR PICK-UP _____ CREATE PDF _____ northwestern memorial hospital 251 East Huron Street Medical Records-Customer Service Galter/2nd Floor / 2-158 Chicago, Illinois 60611-2908 Phone: 312-926-3248 Fax: 312-926-3093 Please mail AUTHORIZATION form to the appropriate address listed above Print Patient's Name_____ Address_____ City/State/Zip_____ Date of Birth ____/____/_____ Last 4 digits of SSN _____ Phone ( ) _____ I _____ hereby authorize northwestern memorial HealthCare to RELEASE (written/oral/electronic) INFORMATION to: Agency/Facility/Person_____ Address: _____ City/State/Zip___
AUTHORIZATION FOR RELEASE OF INFORMATION Records to be released from: HOLD FOR PICK-UP _____ CREATE PDF _____ Northwestern Memorial Hospital
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