Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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