The Best Medics, Doctors & Physicians for A Healing Touch
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780 Canton Road, NE Suite 350
Marietta, Georgia 30060
TEL: (404) 943-0289
FAX: (404) 943-9787
MONDAY - FRIDAY
8:00 AM - 4:30 PM
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Cardiología Pediátrica
Medicina Preventiva Familiar
Telemedicine
Nuevos Pacientes
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Dr. Eduardo Montana
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Inicio
Servicios
Cardiología Pediátrica
Medicina Preventiva Familiar
Telemedicine
Nuevos Pacientes
Testimonios
Staff
Dr. Eduardo Montana
Consultorios
Educación al Paciente
Contáctenos
Inicio
Servicios
Cardiología Pediátrica
Medicina Preventiva Familiar
Telemedicine
Nuevos Pacientes
Testimonios
Staff
Dr. Eduardo Montana
Consultorios
Educación al Paciente
Contáctenos
Inicio
Servicios
Cardiología Pediátrica
Medicina Preventiva Familiar
Telemedicine
Nuevos Pacientes
Testimonios
Staff
Dr. Eduardo Montana
Consultorios
Educación al Paciente
Contáctenos
Solicitud de Registros Médicos
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Solicitud de Registros Médicos
Authorization to release medical record information
Nombre*
Apellido*
Fecha de Nacimiento*
Fecha de nacimiento*
I authorize Childrens Cardiviovascular Medicine to realease my medial record to:
Nombre*:
Dirección*:
Ciudad*:
Estado*:
Código postal*:
Teléfono*
Fax
I authorize Childrens Cardiovascular Medicine to release my medical records to:
All medical sources, including any health plan, physician, health care professional, hospital, clinic, laboratory, pharmacy, medial facility, or other health care provider that has provided payment, treatment or services to me or on my behalf
Please release the following documentation:
Complete Chart
Discharge summaries
Consultations
Lab Work
X-Rays
Skin test Other
Other:
This authorization,as may be. applicable, extends to any medical records covered by any privilege, including without limitation to psychiatric, psychological and mental and records; records relating to drug treatment and/or substance abuse; records related to sexually transmitted diseases and/or social service notes.
Firma del Paciente*:
Date*:
Authorization expires one year after it is. signed:
First request:
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First request
Second request
Third request
Acepto términos y condiciones
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