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Welcome to Pulmonary Medicine of Dayton, Inc. We look forward to serving you. Kindly fill out - page 7 / 8

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Pulmonary Medicine of Dayton, Inc. 6728 Loop Road, Suite 304 Centerville, OH 45459 Phone: (937) 439-3600 Fax: (937) 439-3786

Pulmonary & Critical Care Medicine Felipe A. Rubio, M.D. Hemant M. Shah, M.D. Mariano M. Iberico, M.D. Salman S. Razi, M.D. Median Ali, M.D.

Internal Medicine Ivo C. Seni, M.D Patrick U. Mezu, M.D. Keren Ray, D.O. Edgar R. Santillan, M.D. Jose Torres, M.D. Michele L. Evanson, D.O. Gnanam Thambipillai, M.D. Anne Reddington, D.O.

Authorization For Transfer of Medical Records

Expires:

____________

Patient’s Name:

__________________________________________________________

Address: ________________________________________________________________

City, State, ZIP Code: ____________________________ Telephone:

________________

D a t e o f B i r t h : _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ S o c i a l S e c u r i t y # : _ _ _ _ _ _ - _ _ _ _ _ _ - _ _ _ _ _ _ _

I hereby authorize ____________________________________ to transfer my medical records and any other medical information necessary for the purpose of continuing medical care and/or _____________________. This authorization includes release of information concerning HIV testing or treatment of AIDS, AIDS-related conditions, drug and alcohol abuse,

drug-related conditions, alcoholism, and/or psychiatric/psychological conditions. Records to be released

to: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

_______________________________________________________

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Information Requested

( ) History/Physical ( ) Physician’s Letters ( ) Pulmonary Function Tests ( ) EKG Interpretations ( ) Skin Testing/PPD ( ) Copies of Entire Record

( ) X-Ray Reports/CT Scans ( )Other-Please Specify:_______________ ________________________________________ ____________________________

I understand that I am responsible for its content and will in no way hold the above responsible for the disclosure of information revealed in my medical records. I acknowledge the right to revoke this authorization in writing according to Pulmonary Medicine of Dayton, Inc.’s Notice of Privacy Practices.

Patient Signature _________________________________________________________ Staff Member Completing Authorization________________________________________ Today’s Date_____________________________________________________________

7

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