www.northwesternobgyn.com - Patient Request for Medical Records

Patient Request for Medical Records
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Information Requested (select all that apply)

Other
Purpose of Disclosure

Other
Unless checked below, I understand that released information may include the following information, check if you do NOT want to include:
Send my requested information to
Name of Facility, Person, Company
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Email Address
example@example.com
Please Note Records Preference
Expiration and Revocation

This authorization will expire one year from the date signed unless otherwise specified:
Signature:
Signature of Patient or Legal Representative
Patient or Legal Representative Name

First NameLast Name
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship (if not patient)
Northwestern Women’s Health Associates

680 N. Lake Shore Drive, Suite 1200, Chicago, IL 60611

Tel: 312.440.9400 Fax: 312.440.0423
Should be Empty:

Patient Request for Medical Records