Illinois Authorization For The Release of Medical Information
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NYE PARTNERS IN WOMEN’S HEALTH
625 N. Michigan Avenue Suite 210
Chicago, Illinois 60611
Telephone: 312-670-2530
Fax: 312-670-2630

AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION

______________________________________
Patient’s Name (PRINT)

____________________________
Office Medical Record #

______________________________________
Patient’s Signature
Date of Birth

____________________________

______________________________________
Social Security Number

____________________________

DATE

If not patient, signature and relationship
of person giving authorization

[ ] I authorize NYE Partners in Women’s Health to send a copy of my medical records to:
[ ] I authorize NYE Partners in Women’s Health to request my medical records from:
_____________________________________________________________________________
Name of Physician

Health Care Facility

________________________________________________________________________________
Street Address
__________________________________