Medical Record Release Form

Elias Kassab, MD, FACC, FSCAI, FACP, FASA, RPVI, FAHA, FSVM
Ashok Kondur, MD, FACC, FSCAI
Nishit Choksi, MD, FACC, FSCAI
Nishtha Sareen, MD, FACC, FSCAI
Sonela Blaceri, DO
Jodie Kenes, MD, FACC, FSCAI
www.dearborncardiology.com
AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

I UNDERSTAND THAT DEARBORN CARDIOLOGY WILL NOT CONDITION TREATMENT, PAYMENT, ENROLLMENT, OR ELIGIBILITY FOR BENEFITS ON MY PROVIDING OR REFUSING TO PROVIDE THIS AUTHORIZATION
PATIENT NAME:

First NameLast Name
PREVIOUS NAME(S):

First NameLast Name
DATE OF BIRTH:
SOCIAL SECURITY LAST 4 DIGITS:
I REQUEST AND AUTHORIZE:
FAX:
PHONE:
Please enter a valid phone number.
TO RELEASE HEALTHCARE INFORMATION OF THE PATIENT NAMED ABOVE TO:

DEARBORN CARDIOLOGY
5250 AUTO CLUB DR. SUITE 300, DEARBORN MI 48126
PHONE: (313) -724-9000 FAX: (313)-562-9300 (PREFERRED)
THIS REQUEST AND AUTHORIZATION APPLIES TO:

ALL HEALTHCARE INFORMATIONEKGALL CARDIAC TESTINGRECENT LABORATORY RESULTSHOSPITAL CAREOTHER
REDISCLOSURE: I UNDERSTAND THAT THE RECIPIENT MAY NOT LAWFULLY FURTHER DISCLOSE THE HEALTH INFORMATION UNLESS ANOTHER AUTHORIZATION IS OBTAINED FROM ME, OR UNLESS USE OR DISCLOSURE IS SPECIFICALLY REQUIRED OR PERMITTED BY LAW
PATIENT SIGNATURE:

Clear
DATE:
IF SIGNED BY SOMEONE OTHER THAN THE PATIENT, INDICATE
RELATIONSHIP:
THIS AUTHORIZATION EXPIRES NINETY (90) DAYS AFTER IT IS SIGNED

PATIENT HAS A RIGHT TO A COPY OF THIS AUTHORIZATION. A COPY IS AS VALID AS THE ORIGINAL
Should be Empty: