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HEALTH INFORMATION AUTHORIZATION FORM

I grant permission to send a copy of my medical records to:

SUN HEALTH MEDICAL CLINIC, Inc. / Sunita Shailam, M.D. / primary healthcare

427 C St 216 | San Diego, CA 92101-5121 | Telephone: 619.239.4979 | sunhealth.info | Facsimile: 619.239.5960


FROM PREVIOUS PROVIDER

NAME:  ________________________________________________________

ADDRESS:  _____________________________________________________

TELEPHONE:  ___________________________________________________

FACSIMILE (FAX):  ________________________________________________:  


Unless the sender feels other pertinent information is important, sending the following is sufficient:

  • TESTING: LABORATORY, PATHOLOGY (PAP), ELECTROCARDIOGRAM
  • IMAGING: RADIOLOGY, ECHOCARDIOGRAM
  • PROCEDURES: COLPOSCOPY, ENDOSCOPY (COLONOSCOPY), OPERATIVE REPORTS
  • IMMUNIZATIONS
  • ADDITIONAL REQUESTS:   _______________________________________________


REASON

Continuity of Healthcare


RESCINDABLE

I acknowledge that I am permitted at any time to rescind this request.


PATIENT NAME:  _______________________________________________________________

PATIENTDATE OF BIRTH:  _________________________________________________________

PATIENT / REPRESENTATIVE SIGNATURE: ______________________________________________

REPRESENTATIVE RELATIONSHIP TO PATIENT:  __________________________________________

Date:  ______________________________________________________________________


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