Authorization to Obtain Healthcare Information--New Patient

Authorization to Obtain Healthcare Information
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
I authorize the following doctors/hospitals...
1.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Fax Number
Address
2.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Fax Number
Address
3.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Fax Number
Address
4.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Fax Number
Address
5.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Fax Number
Address
6.) Name
Area of Medicine
If hospital, leave blank
Phone Number
Fax Number
Address
...to release
- the last 2 years of office notes
- the last 5 years of labs
- the most recent colonoscopy and path report
- the most recent mammogram
- the most recent Pap smear
- the most recent DEXA scan
- the most recent ECG tracing
- any other imaging or path reports
- a list of all vaccines
- anything else specified in the cover page
to

North Bethesda Primary Care

Fax: 301-941-4404, Phone: 301-941-4414

11300 Rockville Pike, Suite #1015

North Bethesda, MD 20852
Signature*

Clear
Date*

MonthDayYear
Date
Authorized Representative (if not the patient)

First NameLast Name
Relationship of Authorized Representative
Phone Number
Should be Empty: