Authorization to Release Information

Directions:  Please complete the form below and click SUBMIT.  The contents of this form will be electronically transmitted
to the South Florida Bone Marrow/ Stem Cell Transplant Institute and presented to you for an authorized signature
upon your first visit.

I hereby authorize and request:  
to furnish information from my medical records, including:

Physician Letters - Consultation & Follow Up

Specialist Letters - Consultation & Follow Up

Histopathology - Original Reports/Repeat Biopsies

Other Pathology/Cytology Reports

X-rays including CT scans/Nuclear Medicine (Reports & Films)

Laboratory Reports:

          Recent CBC & Platelets, Chemistry including LFT’S

Chemotherapy Flow Sheet

Miscellaneous:  

        

Please fax the above information at your earliest  convenience to (561) 752-5445.  

Please mail the information at your earliest convenience to: South Florida Bone Marrow Stem  Cell Transplant Institute, 10301 Hagen Ranch Road, Suite 600, Boynton Beach, FL  33437  

______________________________________________________________________________

I hereby release South Florida Bone Marrow/Stem Cell Transplant Institute from any liability which may result from this release of confidential medical records or which may arise as a result of the use of information contained in the records released.  I relieve and hereby agree to hold the South Florida Bone Marrow/Stem Cell Transplant Institute and the above named parties free and harmless from any and all liability arising out of this release.

______________________________________________________________________________

Patient Information:

Patient Name:
Date of Birth:
Social Security Number:

                              This form will be valid for one year from date signed