Seattle Urological Associates P.L.L.C.
AUTHORIZATION
TO RELEASE MEDICAL RECORDS
FROM SEATTLE UROLOGICAL ASSOCIATES
I
hereby authorize:
() James E. Gottesman,
M.D., P.S. () Wayne D. Weissman,
M.D., P.S.
() James P. Gasparich,
M.D., P.S. () Joel D. Lilly,
M.D., P.S.
() John S. Mullen, M.D.,
P.S.
to release my medical records to the physician/provider listed below:
Patient’s Physician/Provider_______________________________________________
Mailing Address _______________________________________________________
City, State, Zip ________________________________________________________
Telephone # _________________________ Fax# ____________________________
Including the following
medical information:
( )
Complete records (
) All Urological related records
( )
X-rays (
) CAT & MRI scans
(
) Ultrasound
(
) Nuclear scans
(
) Biopsy results ( ) Pathological slides
(
) All of the above
Special dates of interest ____________________________ to ____________________
I understand that my express consent is required to release any healthcare information relating to test and diagnosis, and/or treatment for HIV (AIDS virus), sexually transmitted diseases, psychiatric disorders, mental health or drug and alcohol use. If I have been tested, diagnosed or treated for HIV (AIDS virus) or sexually transmitted diseases, psychiatric disorders or mental health or drug and alcohol use, you are specifically authorized to release all healthcare information relating to such diagnosis, testing or treatment.
Patient’s Name
___________________________________________________________________
(Last)
(First) (Middle Initial)
Social security# ________________________Date of Birth ______________________
Mailing address________________________________________________________
City, State, Zip_________________________________________________________
Signature __________________________________________ Date ______________