Transcription of Medical Record Number: (for internal purposes)
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Example: biology
Medical Record Number: (for internal purposes)
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATIONHEALTH INFORMATION MANAGEMENT DEPARTMENTNONCH35557 06/1735557 Medical Record number : _____ ( for internal purposes )Patient Name: _____ Last 4 digits of SSN: _____Previous Name, if applicable: _____Address: _____ City: _____ State: _____ Zip Code: _____Date of Birth: _____ Home Phone: _____ Work Phone: _____Email address _____1. Emory HEaltHcarE Facility/FacilitiEs: I authorize representatives from the following facility/facilities to disclose the health information as directed below: (Check one or more): Emory Johns Creek Hospital The Emory Clinic Emory University Hospital Midtown Emory University Hospital Emory University Orthopaedics and Spine Hospital Center for Rehab. Medicine Wesley Woods Health Center Emory Children s Center Wesley Woods Geriatric Hospital Emory Specialty Associates Wesley Woods Outpatient Clinic Dialysis Access Center of Atlanta Budd Terrace Saint Joseph's Hospital of Atlanta Other: _____ The Medical Group of Saint Joseph's, LLC2.
E If you are requesting your medical information via e-mail, please be sure that you have provided us with an accurate e-mail address. E-mail and attachments will be sent to you in an encrypted format with instructions on how you retrieve the information.
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