Seattle Urological Associates P.L.L.C.
Patient’s Physician/Provider___________________________________________
Mailing Address _____________________________________________________
City, State, Zip ______________________________________________________
Telephone # _______________________ Fax# ____________________________
I
hereby authorize the above-mentioned physician/provider to release my
medical records to:
() 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.
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 ______________