Indiana Medical Records Release Form 3
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Authorization for Release of Medical Records

I hereby authorization my physician, ___________________________,
to release my medical records to Dr. James G. Donahue.
_____ Entire chart

_____ Operative Notes

_____ Admission Summary

_____ Lab Results

_____ Discharge Summary

_____ Social History

_____ Psychiatric Evaluation _____ IVF Flow Sheet and Embryo Lab Records
_____Other

Check one for the office you would like for your records to be sent to.
_____ Dr. James G. Donahue
5128 E. Stop 11 Rd.
Suite 38
Indianapolis, In 46237
317-865-0411 Phone
317-859-3815 Fax

_____ Dr. James G. Donahue
8435 Clearvista Pl.
Suite 104
Indianapolis, In 46256
317-595-3665 Phone
317-595-3666 Fax

_____________________________________ _________________
Signature
Date
______________________________________
Print Name

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