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Get NIH-527 2008

Patient/Authorized Signature Patient Identification Print Name Date NIH-527 9-08 P. A. 09-25-0099 File in Section 4 Correspondence. Authorization for the Release of Medical Information MEDICAL RECORD INSTRUCTIONS Complete this form in its entirety and forward the original to the address below Please complete a separate form for each requestor NATIONAL INSTITUTES OF HEALTH ATTN MEDICAL RECORD DEPARTMENT MEDICOLEGAL SECTION 10 CENTER DRIVE MSC 1192 BLDG 10 ROOM 1N205 BETHESDA MD 20892-1192 TELEPHONE 888 790-2133 outside calling area 301 496-3331 local calls FACSIMILE 301 480-9982 IDENTIFYING INFORMATION Patient Name Daytime Telephone Date of Birth REQUESTOR INFORMATION Information is to be released to the following individual or party Name Telephone Address Fax Number City State Zip Code Country Please note that a patient may designate up to two outside care providers to have permanent authorization to obtain copies of their medical records. This authorization may be revoked at any time upon your request. If you would like the above named care provider to have such access or update existing care providers please choose one of the following Please give the above named care provider authorization to my medical records Please replace existing authorization with the above named care provider Please remove the above named care provider s authorization The purpose or need for disclosure Date Range of Information to be Released from to month/year Please check specific information to be released Discharge Summary History Physical Operative Reports Outpatient Progress Notes Consultation Reports Pulmonary Function Tests Tissue Exam Reports Nuclear Medicine Reports bone scan etc* Heart Diagnostics Radiology Reports Radiology CD Images CT/x-ray etc* Lab Results Other Please Specify AUTHORIZATION Permission is hereby granted to the National Institutes of Health Clinical Center to release medical information to the individual/organization as identified above. Note submission of this form authorizes the release of the information specified within one year from date of signature. Authorization for the Release of Medical Information MEDICAL RECORD INSTRUCTIONS Complete this form in its entirety and forward the original to the address below Please complete a separate form for each requestor NATIONAL INSTITUTES OF HEALTH ATTN MEDICAL RECORD DEPARTMENT MEDICOLEGAL SECTION 10 CENTER DRIVE MSC 1192 BLDG 10 ROOM 1N205 BETHESDA MD 20892-1192 TELEPHONE 888 790-2133 outside calling area 301 496-3331 local calls FACSIMILE 301 480-9982 IDENTIFYING INFORMATION Patient Name Daytime Telephone Date of Birth REQUESTOR INFORMATION Information is to be released to the following individual or party Name Telephone Address Fax Number City State Zip Code Country Please note that a patient may designate up to two outside care providers to have permanent authorization to obtain copies of their medical records. This authorization may be revoked at any time upon your request. If you would like the above named care provider to have such access or update existing care providers please choose one of the following Please give the above named care provider authorization to my medical records Please replace existing authorization with the above named care provider Please remove the above named care provider s authorization The purpose or need for disclosure Date Range of Information to be Released from to month/year Please check specific information to be released Discharge Summary History Physical Operative Reports Outpatient Progress Notes Consultation Reports Pulmonary Function Tests Tissue Exam Reports Nuclear Medicine Reports bone scan etc* Heart Diagnostics Radiology Reports Radiology CD Images CT/x-ray etc* Lab Results Other Please Specify AUTHORIZATION Permission is hereby granted to the National Institutes of Health Clinical Center to release medical information to the individual/organization as identified above. .

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