South Denver Gastroenterology Authorization to Release Medical Records
Phone: 303-788-8888 or 303-790-7334 Email: Medical_records@gutfeelings.com
Physician or facility to release records (From)
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Patient name
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Date of Birth (DOB)
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Last 4 of SSN #
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Information requested
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Please Select
Procedure Reports
Pathology Reports
Lab/Blood Work
Radiology
Entire Chart
Other
Please specify the other information requested, if applicable
Name to release records to
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Address
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Phone
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Fax
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Signature
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By signing this form, I authorize the healthcare provider to release the information listed above, which may include the following: Drug Abuse, Substance Abuse, Psychological/Psychiatric issues and/or AIDS/HIV.
Date
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Person authorized to sign for patient
By signing this form, I authorize the healthcare provider to release the information listed above, which may include the following: Drug Abuse, Substance Abuse, Psychological/Psychiatric issues and/or AIDS/HIV.
Date
Submit
Should be Empty: