Authorization For Release Of Medical Information To Vumc - Vanderbilt University Medical Center

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AUTHORIZATION FOR RELEASE OF
MEDICAL INFORMATION TO VUMC
(VANDERBILT UNIVERSITY MEDICAL CENTER)
Name:__________________________________________________
PATIENT IDENTIFICATION
Date of Birth_________________ S.S.#______________________
Maiden/Other names known by:
RELEASE RECORDS TO:
Vanderbilt Medical Center
(Physician or Facility to which
Name: ______________________________________________________
Student Health Center
records should be sent)
Address: _____________________________________________________
Zerfoss Building, Station 17
phone: _____________________
(615) 322-2427
Nashville, TN 37232-8710
City/State/Zip:_________________________________________________
Fax: ______________________
(615) 343-0047
Name:_______________________________________________________
PROVIDER
Address:_____________________________________________________
Phone:
(Who is releasing the information)
City/State/Zip_________________________________________________
Fax:
Dates:_______________________________________________
DATES OF TREATMENT
INFORMATION TO BE SENT:
LAB/PATHOLOGY
CLINIC NOTES
H&P
PT,OT, SLT
DISCHARGE SUMMARY
OP REPORT
X-RAY, CT
OTHER
Medical Care
Insurance
At the request of the patient
Other, Please Explain:_________________________________
PURPOSE OF RELEASE
I understand that I may refuse to sign this authorization, and that my refusal to sign will not affect my ability to obtain
treatment. I understand that this authorization may be revoked in writing at any time, except to the extent that action
has been taken in reliance of this authorization.
I understand that the information released may be subject to re-disclosure by some recipients and may no longer be
protected by federal and state privacy rules related to health information.
This authorization expires:___________________________________(if blank, then 90 days after date of signature)
To revoke this authorization, please send a written request to the provider listed above.
Signature of Patient/Legal Representative:_____________________________________ Date:________________
Relationship to Patient:_________________________________________________________________________
MC 2900 (7/2003)

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