1. I hereby authorize Columbia Presbyterian Eastside Radiology to release the following information from the health records of
Patient Name: 
Date of Birth: / /
Address:
2. Information to be released:
3. Information to be released to:
4. Purpose of disclosure:
5. The facility, its employees and officers and staff physicians are released from legal responsibility or liability for the release of the above information to the extent indicated in the authorized herein.
|
Patient or Legal Guardian
