Request for Medical Records

Patient Medical Records Release Authorization
________________________________________________________________________________________________________________

Send records to Lyndon D. Taylor, MD
1100 Lake Street, Suite 260 - Oak Park, Illinois 60301
Telephone # (708) 848-9440 - Fax # (708) 848-4415

FROM:

Patient Name________________________________ Birthdate_________________  SSN____________________

Address______________________________  City____________________  State___________________  ZIP_________________

TO:

Medical Records Department

Facility Name_________________________  Fax____________________  Tel.____________________

Address______________________________  City____________________  State__________________  ZIP_________________

You are hereby authorized to release to Dr. Taylor my medical records concerning uterine fibroids, including diagnostic imaging, performed on me between _____________(beginning date) and _________________(recent date) at your facility, as well as operative reports for surgery performed between ____________________(beginning date) and ____________________(recent date).

I understand I have a right to refuse to sign this Authorization, and to inspect and copy the health information to be released. If I do not sign this Authorization, the hospital named above will not release my health information. Dr. Lyndon Taylor will not refuse to treat me based on whether I agree to allow my health information to be used and disclosed to others.

I understand that I may revoke this Authorization at any time by giving written notice to your facility and Dr. Lyndon Taylor, but that this revocation will not be valid if action has already been taken to release my health information based on this Authorization, or if this Authorization is granted to obtain insurance coverage, which is covered under other law.

I understand that the health information covered by the Authorization may be re-disclosed and no longer protected by Federal privacy rule.


This Authorization is valid for one (1) year from the date signed unless limited by the following event, condition, or date: _____________________________________________________________________

Patient Signature______________________________  Date____________________


DEAR PATIENT: PLEASE PRINT THIS PAGE, FILL IT OUT COMPLETELY, AND FAX IT TO THE FACILITY/PHYSICIAN WHERE YOU WERE DIAGNOSED OR TREATED. ALSO FAX A COPY TO DR. LYNDON TAYLOR AT (708) 848-4415.