Print this page and fax/mail/take to your doctors.
Request for Release of Medical Records
and
Patient Authorization to Disclose Health Information
Dear Physician / Medical Facility: ______________________________________________
Physician Telephone: ___________________________ Fax: _______________________________
I hereby authorize you, and request of you to forward to the Norman Parathyroid Center my pertinent medical records. I am giving my consent to the release and disclosure of my personal health information to:
Norman Parathyroid Center
2400 Cypress Glen Drive
Wesley Chapel, FL 33544James Norman, MD, FACS, FACE
Douglas Politz, MD, FACS, FACE
Jose Lopez, MD, FACS
Please FAX the following records to: 813-972-0077
| * All lab reports | * Progress notes pertaining to high calcium / parathyroid issues |
| * All biopsy/pathology reports | * Results from any parathyroid scans (sestamibi or thyroid ultrasound) |
| * Recent bone density tests (DEXA scans) |
* Any records pertaining to neck surgery, thyroid/parathyroid issues |
Patient Name ________________________________________________________
Address ____________________________________________________________
City _________________________ State __________________ Zip __________
Date of Birth ______ / _____ / _______ SS# ________ - _____ - _________
Patient Signature ______________________________________ Date: _________