Download LUMC Medical Records

Section of Pediatric Urology
Department of Urology
2160 South First Avenue
Maywood, IL 60153
708/216-6266
708/216-6585 FAX
Authorization for Release of Health Information
This is to authorize:
Loyola University Medical Center – Medical Records
(name of institution holding medical records/data)
Address:
2160 S. First Avenue
Maywood, IL 60153
708-216-5004
708-216-5947 Fax
to release to:
the following medical data:
Patient:
Address:
Date of birth:
Radiology, nuclear medicine reports;
Date:
X-ray, ultrasound, nuclear medicine films:
Date:
Other:
Date:
For the purpose of Health care
This authorization includes permission for the institution/person named above to
view and/or copy the data specified. This authorization is valid until
or 90 days from date of authorization.
The person authorizing the release of this information has the right to inspect the
data prior to its release and the right to revoke consent at any time by notification in
writing. The information has the potential to be re-disclosed and therefore no longer
protected. Treatment, payment or eligibility for care is not conditioned on obtaining the
patient authorization.
Signature of Patient or Legal guardian
Witness
8/9/2017
Date of Signature
Witness