Medical Information Release Authorization Form
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1
2MEDICAL INFORMATION RELEASE AUTHORIZATION
Infectious Disease &
The Medical Center
Medical Center Urgentcare
Travel Medicine
250 Park Street
1110 Wilkinson Trace
825 Second Ave. East, Suite C1
Bowling Green, KY 42101
Bowling Green, KY 42103
Bowling Green, KY 42101
The Medical Center at Scottsville
Bluegrass Outpatient Center
ENT of Bowling Green
456 Burnley Road
/ Just for Women
340 New Towne Drive
Scottsville, KY 42164
1110 Wilkinson Trace
Bowling Green, KY 42103
The Medical Center at Franklin
Bowling Green, KY 42103
Rural Health Clinic
1100 Brookhaven Road
Women’s Health Specialists
466 Burnley Road
Franklin, KY 42134
350 Park Street, Ste. 203
Scottsville, KY 42164
The Medical Center at Caverna
Bowling Green, KY 42101
Scottsville Primary Care Clinic
1501 South Dixie St
217 West Main St.
Who is releasing
Horse Cave, Ky 42749
Medical Center Psychiatry
Scottsville, KY 42164
information
A Department of The Medical Center
The Medical Center at Albany
Fountain Run
Adult Psychiatry
723 Burkesville Road
Child & Adolescent Psychiatry
Rural Health Clinic
Albany, KY 42602
47 Akersville Road
350 Park Street, Ste. 204
Commonwealth Regional
Bowling Green, KY 42101
Fountain Run, KY 42133
Specialty Hospital
Barren River Regional
250 Park Street
Medical Center Primary Care
Cancer Center
Bowling Green, KY 42101
1901 Scottsville Rd
103 Trista Lane
The Heart Institute
Bowling Green, KY 42104
Glasgow, KY 42141
350 Park Street, Suite 210
Medical Center Orthopaedics
CHC Employee Health Services
Bowling Green, KY 42101
720 Second Avenue, Ste. 207
825 Second Ave East Suite C2
Neuroscience Services
Bowling Green, KY 42101
Bowling Green, KY 42101
825 Second Avenue, Ste. C3
Primary Clinic at Munfordville
________________________
Bowling Green, KY 42101
1134 Main St. P.O. Box 340
________________________
Surgical Weight Loss Program
Munfordville, Ky 42765
825 Second Avenue, Ste. A4
________________________
Primary Clinic at Caverna
Bowling Green, KY 42101
1495 South Dixie Street
Horse Cave, Ky 42749
Name:________________________________________________________________
Patient
Identification
Date of Birth:___________________________SS#____________________________
Name:_________________________________________________________________
Address:_______________________________________________________________
Release records to
Phone:__________________________________Fax #:___________________________
Dates:_________________________________________________________________
Type of treatment: (may include psychiatric, drug or alcohol abuse)
Dates of treatment
_____ ER _____ Outpatient _____ Inpatient
_____ Medical Care
_____ Insurance
_____ Legal Claim
Reason for release
_____ Other, Please explain:_______________________________________________
______________________________________________________________________
_____ H & P
_____ DG SUMM
_____ OR REPORT
_____ PATH
_____ X-RAY
_____ ER REPORT
Information you
_____ ENTIRE
_____ OUTPT
want released
_____ LAB (May include AIDS/HIV information)
(Check what you want)
_____OTHER ____________________________________________________________
____________________________________________________________
____________________________________________________________
Account Number _____________________________________
MEDICAL INFORMATION
RELEASE AUTHORIZATION
600195 (230) Rev. 4/16
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