CSMG - Medical release forms

MEDICAL RECORDS FROM MEDICAL PROVIDERS

AUTHORIZATION TO OBTAIN OR RELEASE MEDICAL RECORDS FROM MEDICAL PROVIDERS
KAUSTUBH V. PATANKAR, MD, FACC | MIMI SEN BISWAS, MD, MHSC | NADER N. ATTIA, DO | NIRAJ V. PAREKH, MD | JEREMY, COX, DO | JATIN N. AMIN, MD | BRADLEY S. MESSENGER, MD | SANDEEP SANGODKAR, DO. FACC | CHRISTOPHER SEAMAN, MD |

Authorization to obtain medical records:

I hereby authorize Cardiology Specialists Medical Group to obtain any and all medical records concerning my care from any physician, hospital, or other healthcare professionals that have or will provide me with medical care.

Authorization to release medical records:

I also authorize Cardiology Specialists Medical Group to release any and all medical records concerning my care to any physician, hospital, or other healthcare professionals that have or will provide me with medical care.

Additionally, I authorize Cardiology Specialists Medical Group to release any and all medical records concerning my care to Medicare, Medicaid, other health insurance companies, third party administrator, or managed care companies.
Consent to obtain Medical records*

Yes, I authorize CSMG to obtain my medical records as stated aboveI do not consent (This may prevent your Cardiologist from providing a complete evaluation)
Consent to the release of Medical records*

Yes, I consent to the release of Medical records from medical providersI do not consent to the release of Medical records from medical providers
Patient Signature (draw with mouse or finger)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date*

MonthDayYear

	FIRST NAME	LAST NAME	RELATIONSHIP	Date of Birth
Designated 1
Designated 2
Designated 3

MEDICAL RECORDS FROM MEDICAL PROVIDERS

MEDICAL RECORDS RELEASE TO TRUSTEE(S)