Consent for medical records

Consent for medical - I hereby release the Medical Office of MJ Scheinbaum MD its representatives agents consultants and its counsel from all

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M. Joel Scheinbaum, MD 642 oxford Ave. Venice, CA 90291 Tel: (310) 266-5545 Fax: (310) 306-4036 Psychiatry CONSENT TO RECEIVE AND RELEASE MEDICAL AND HEALTH CARE INFORMATION, RECORDS, AND REPORTS I, _________________, Hereby give permission to the Medical Office of MJ Scheinbaum, MD, Their Physicians, personnel, or their legal counsel to disclose in any ‘report’ provided by the evaluating physician any and all health care information in their possession that has been provided to them, including information provided by me in any form to the parties and/or agencies that have directed me to this evaluation. I understand that the Medical Office of MJ Scheinbaum, MD, has no control over how the referring parties utilize or disseminate this information.
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Unformatted text preview: I hereby release the Medical Office of MJ Scheinbaum, MD, its representatives, agents, consultants, and its counsel from all liability and all claims of any nature whatsoever pertaining to disclosure of information, or of any professional opinions, findings, or recommendations as contained in the information, records, and reports to which this release applies. Date: ______________________ Full Name: _____________________________ Signature: _____________________________ Social Security Number: __________________ Date of Birth: ___________________________ Adress: _______________________________...
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This note was uploaded on 10/27/2011 for the course PHYCOLOGY 101 taught by Professor Eins'tein during the Spring '11 term at Albany Medical College.

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