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| Authorization to Release Patient Information – Department of Medical Records – page 1 Telephone: 609-893-4645 Fax: 609-893-5953 This request will not be processed unless all areas are completed. |
| Patient Name: |
| Address: |
| Date of Birth: |
| I, hereby authorize Deborah Heart and Lung Center to release my health information described below: |
| To: |
| Address: |
| Telephone number: |
| Service date: |
| Documents/Information to be released, please be specific: (note: only a medical summary of your visit will be released, unless specific tests are requested) |
| Purpose of disclosure, please explain or indicate "at the request of the individual" |