wesley medical center medical records

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AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION (PHI) Instructions: ? Sections 1 6 must be completed. If any section is not complete, this authorization will be considered incomplete
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Date of diagnosis: Date: Time of treatment: Please use bold if needed. Type: Type: (D) Date of birth: Date entered: Patient's First Name: Patient's Last Name: Patient's Sex: Gender: Female Male Patient has not had a previous MRI scan: Patient has had MRI scan more than one time. You may include other conditions or previous diagnoses (e.g. depression, dementia) in the summary provided. If a prescription drug has been prescribed for the patient in this case, use the pharmacy name instead (e.g. Zoloft for Patient: D. H. Jones). If a combination of medications has been prescribed, the medications will appear in the following order: (drug first, name of second medication). Type: Type: (D) Date of birth: Type of procedure: Type of surgery: (D) Date of surgery: Patient Type: Type 2 (D) Date of diagnosis: (D) Date of treatment: A1 D2 Your completed authorization should be faxed to: Release of Information University of Michigan Medical Center 300 S. Huron St.
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