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St Vincents Obstetrics And Gynecology Authorization For Release Of Medical Information
Get St Vincents Obstetrics And Gynecology Authorization For Release Of Medical Information
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Patient Name: Birth Date: Address: SSN: Telephone #: I hereby authorize ST. VINCENT SOB/GUN and its affiliates to release the following information.
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Revoke FAQ
Call 205-930-7724 to request an Authorization for Use or Disclosure of Patient Information form. The form can be mailed to the address provided by the patient or faxed. Complete the Authorization for Use or Disclosure of Patient Information form and fax to 205-930-6721.
To obtain your own medical records: Print out the Consent to Release of Information form, and complete as many areas as you are able. Bring this completed form to the medical records department, and you can pick up your records.
Questions? Please call the Health Information Management (HIM) Department at 317-338-2216 for Ascension St.
You can access this information online through our patient portal, or request a physical copy by contacting us at (508) 363-9471. Records requests generally take 30 business days to fulfill.
Questions? Please call the Health Information Management (HIM) Department at 317-338-2216 for Ascension St.
To obtain your own medical records: Print out the Consent to Release of Information form, and complete as many areas as you are able. Bring this completed form to the medical records department, and you can pick up your records.
Specified Related content
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