MEDICAL AND HOSPITAL RECORDS RELEASE AUTHORIZATION
TO: Massachusetts General Hospital
121 Innerbelt Road
Somerville, MA 02143
RE: Records of Patient: Bernard J. Wolfe, Jr. SS# , MGH# 043 48 28 DOB
Office Address: PO Box 64, Woodsville, NH 03785 tel. 603-747-2338 Fax 603-747-3356 email email@example.com
Home Address: 1095 Woodsville Rd., Monroe, NH 03771, tel. 603-638-4401
You are hereby authorized to furnish and release to the person/entity/institution named at the address set out below copies of all medical records set forth covering findings, treatment rendered and opinions as to my condition as more fully set out in my letter dated June 20, 2003 attached hereto. Any information and records regarding my condition is confidential and privileged and may not be disclosed without written authorization by me. This authorization shall remain in full force and effect until revoked by me in writing.
Please forward the following as may be requested by the authorized party pertaining to Bernard J. Wolfe, Jr. concerning treatment and diagnoses by Dr. Thomas Dodson based on an appointment on May 27, 2003 and later reading and evaluation of a CTScan films and reading furnished by Cottage Hospital. Also including but not limited to all itemized bills, hospital records, Reports and notes on all evaluations, any surgical procedures, all x-rays, ultrasounds and related reports, all laboratory reports.
Signature of Patient
Release said records to:
Bernard J. Wolfe, Jr.
PO Box 64
Woodsville, NH 03785