Transcription of FROM: TO - Advocate Health Care
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White - Original in the Medical Record Yellow - Copy to the PatientAUTHORIZATION FOR release OF PATIENT Health INFORMATION00-5013 03/07*005013*Patient Name_____Address_____Phone Number_____Date of Birth_____ Medical Record Number_____ authorization FOR release OF PATIENT Health INFORMATIONI hereby authorize that the protected Health information regarding the above-named person be forwarded: FROM: Person/Institution_____ Address_____ City_____State_____Zip_____TO:Person/Ins titution_____ (Recipient) Address_____ City_____State_____Zip_____Purpose or need for information:_____Disclosure will include: (check all that apply) Face Sheet History & Physical Laboratory Report Operative Report Other _____ Discharge Summary Progress/Physician Notes
White - Original in the Medical Record Yellow - Copy to the Patient AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INFORMATION …
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