A Gynecologist's Second Opinion:
The Questions & Answers You Need to Take Charge of Your Health
(Second Edition, Revised)
by William H. Parker
Fill out this form to receive this book mailed to you free of cost . Submit your postal address to receive a free copy of A Gynecologist's Second Opinion: The Questions & Answers You Need to Take Charge of Your Health (Second Edition, Revised)
 
OPT-IN TO GET THE FREE BOOK !  
 

Visit the Virtual Practice of Dr. Lyndon Taylor on HealthTap

Request for Medical Records

Patient Medical Records Release Authorization
__________________________________________________________________________

Send records to Lyndon D. Taylor, MD
1100 Lake Street, Suite 260 - Oak Park, Illinois 60301
Telephone # (708) 848-9440 - Fax # (708) 848-4415

FROM:

Patient Name________________________________ Birthdate_________________  SSN____________________

 

Address______________________________  City____________________  State___________________  ZIP_________________

 

TO:

Medical Records Department

 

Facility Name_________________________  Fax____________________  Tel.____________________

 

Address______________________________  City____________________  State__________________  ZIP_________________

 

You are hereby authorized to release to Dr. Taylor my medical records concerning uterine fibroids, including diagnostic imaging, performed on me between _____________(beginning date) and _________________(recent date) at your facility, as well as operative reports for surgery performed between ____________________(beginning date) and ____________________(recent date).

 

I understand I have a right to refuse to sign this Authorization, and to inspect and copy the health information to be released. If I do not sign this Authorization, the hospital named above will not release my health information. Dr. Lyndon Taylor will not refuse to treat me based on whether I agree to allow my health information to be used and disclosed to others.

 

I understand that I may revoke this Authorization at any time by giving written notice to your facility and Dr. Lyndon Taylor, but that this revocation will not be valid if action has already been taken to release my health information based on this Authorization, or if this Authorization is granted to obtain insurance coverage, which is covered under other law.

 

I understand that the health information covered by the Authorization may be re-disclosed and no longer protected by Federal privacy rule.

 

This Authorization is valid for one (1) year from the date signed unless limited by the following event, condition, or date: _____________________________________________________________________

 

Patient Signature______________________________  Date____________________

 

DEAR PATIENT: PLEASE PRINT THIS PAGE, FILL IT OUT COMPLETELY, AND FAX IT TO THE FACILITY/PHYSICIAN WHERE YOU WERE DIAGNOSED OR TREATED. ALSO FAX A COPY TO DR. LYNDON TAYLOR AT (708) 848-4415.

CLICK HERE TO RETURN TO THE PREVIOUS PAGE

 
 
Email Newsletter icon, E-mail Newsletter icon, Email List icon, E-mail List icon Enter Email To Stay Informed
 
 
Obstetrics-Gynecology Handout Index
 
 
Reviews

Appointment
Uterine Fibroids Fibroid Embolization, fibroid doctors in chicago, chicago fibroid doctor, fibroid doctor Chicago, Oak Park IL, River Forest IL, Maywood IL Berwyn, Cicero, Franklin Park, Westchester, Melrose Park, Hillside, Bellwood, Riverside, North Riverside, Lyons, LaGrange, Western Springs, Brookfield, Hinsdale, Oak Brook, Lombard, Elmhurst, Northlake, schiller park, franklin park il.