THE PURPOSE OF THIS RELEASE IS FOR: [ ] Moved [ ] Changing insurance
[ ] Second opinion [ ] Primary Care Physician update [ ] Changing physicians
EXPIRATION NOTICE: I understand that this consent is revocable at any time prior to the release of information. This authorization will expire 90 days from the date signed.
RECORDS FROM OTHER HEALTH FACILITIES/REDISCLOSURE: It is the policy of NYE Partners in Women’s Health to release only medical information documented or dictated by NYE Partners in Women’s Health care providers. If you have been treated by other health care providers, please contact them and make arrangements to release any information you may need. Federal regulations prohibit us from redisclosing information without the specific written consent of the person(s) to whom it belongs.
ANY FEES INVOLVED IN THE TRANSFER OF RECORDS TONPWHFROMA PREVIOUS PROVIDER ARE THE RESPONSIBILITY OF THE PATIENT
Illinois Authorization For The Release Of Medical Information PDF Thumbnail Preview