Release of Information Form

Authorization to Request Information
StrykerMD

Jeanne N. Stryker MD DABR
Mailing Address: 153 South Sierra Avenue # 990

Solana Beach, CA 92075

Office: 858-480-1977

Fax: 888-625-8230

www.strykermd.net
Name*

First NameLast Name
Birth Date*

MonthDayYear
Email
example@example.com
Last 4 SSN
I, hereby authorize Name of person or facility which has medical information. Please included the phone number or fax number:*
Type in the name of person or facility
AUTHORIZATION FOR REQUEST OF PROTECTED HEALTH INFORMATION*
To release the following health information: Most Recent Blood Work, Pathology and/or Biopsy Report. Foundation Medicine test Results . Most recent physical Imaging (CD) with reports and medical clinic notes. To: Stryker Interventional Specialists Jeanne N. Stryker MD 153 South Sierra Avenue Suite 990 Solana Beach, CA 92075 Office: 858-480-1977 Fax: 888-625-8230 For the following purposes: Release of Medical Imaging such as PET CT, MRI, Ultrasound, CT, Mammogram and/or other pertinent medical imaging. I understand that by signing this authorization: • I authorize the use or disclosure of my individually identifiable health information as described above for the purpose listed. • I have the right to withdraw permission for the release of my information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed. • I have the right to receive a copy of this authorization. • I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization. • I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.(List as specifically as possible, for example: name, dates of service, any documents).
Purpose for Information Requested
Jeanne N. Stryker MD to review my medical imaging for the purpose of a treatment plan.(List as specifically as possible, for example: to receive benefits).
Release Information to the Following
Name

First NameLast Name
Organization
Phone Number
Fax Number*
Email Address*
Delivery Method*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Continued Medical Care

Continued Medical CareLegal PurposesInsurance PurposesPersonal InterestOther
Release Date Expiration

MonthDayYear
Date
Consent*

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.
Signature*

Clear
Sign by using a touch tablet/screen or left click and hold as you sign with your mouse.
Should be Empty:

Authorization to Request Information

StrykerMD

Release Information to the Following