Patient's InformationPatient's Full Name(Required) First Last Phone Number(Required) Email(Required) Patient's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Physician's InformationName of Facility / Physician(Required) Physcian's Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code I hereby authorize St. Louis Medical Clinic or a representative to obtain the following medical information:Designated Record Set Designated Record Set From(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Admission / Discharge Summary Admission / Discharge Summary From(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Immunization Record Immunization Record Mental Health Notes Mental Health Notes Laboratory Records Laboratory Records From(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY X-Ray films and report(s) X-Ray films and report(s) From(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Mammogram(s) and report(s) Mammogram(s) and report(s) From(Required) MM slash DD slash YYYY To(Required) MM slash DD slash YYYY Entire Medical Record Entire Medical Record Other Other (Must be specified) Other(Required) By checking this box, I consent to the following:(Required) I hereby authorize St. Louis Medical Clinic or a representative to obtain the following medical information.This authorization is give freely with the understanding: 1. Any and all records, whether written, oral or in electronic format, are confidential and cannot be disclosed without prior written authorization. 2. A photocopy or fax of this authorization will be as valid as the original. 3. I may revoke this authorization at any time, except where information has already been obtained. This authorization is valid for ninety (90) day period from the date of consent.Today's Date(Required) MM slash DD slash YYYY Δ
