Release of Records from Dr. Searles| grantsearlesmd

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ANCHORAGE SURGICAL & BARIATRIC

The Professional and Personal Care You Deserve

Authorization to Release Health Care Information

Patient's Name:*

Date of Birth*

Month

Day

Year

Social Security #:*

Previous Names:*

I request and authorize release from:

Grant Searles, MD, FACS | Anchorage Surgical & Bariatrics

1200 Airport Heights Dr. Suite 350 Anchorage, AK 99508

P#: 907-277-1197 F#: 907-277-1139

For the purpose of:*

Treatment

Workers Comp.

Insurance

Legal

Personal (at the request of the patient)

Other

TO:*

Mailing Address*

Phone Number*

Fax Number*

For dates of service*

This request & authorization applies to: *

Clinic Reports

Consultations

Discharge Summary

EKG/Cardio Results

History & Physical

Hospital & Emergency Department Reports

Immunizations

Laboratory Results

Pathology Results

Problem & Medication Lists

Radiology Films/Imaging

Radiology Results

Other

P# 907-277-1197 F# 907-277-1139

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