District of Columbia Authorization for Release of Health Information FormDistrict of Columbia Authorization for Release of Health Information Form
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JOHNS HOPKINS HOSPITALS
Johns Hopkins Hospital
Johns Hopkins Bayview Medical Center
Howard County General Hospital
Suburban Hospital
Sibley Memorial Hospital

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
Complete all sections of this Authorization as appropriate to your request.
Patient Name:

_____________________________________________
(first)

(m. initial)

____________________________________________

Address:

Birth Date:

__________________

Phone #:

_______________

(last)

(street address)

________________________________________________
(city)

(state)

Medical Record #: __________________

(if known)

(zip code)

WHO
I hereby authorize ______________________________________________________________________to take the following action.
(fill in above the name of the Johns Hopkins hospital where your medical information is held)

ACTION REQUESTED (check one)
Provide a copy of My Health Information to me
Release My Health Information to:

Let me look at My Health Informatio