Authorization for Release of Medical Information

Authorization for Release of Medical Information

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Authorization for Release of Medical Information for Jain Foundation Patient Registry

If we need to obtain your medical information from multiple providers, please complete a separate form for each medical provider with their respective contact information
Date of Birth(Required)
Patient Address(Required)

We are requesting records from your neurologist, physician, MDA clinic, family member or diagnostic/research lab about your muscle disease only.

I authorize the Jain Foundation Inc. to obtain information from:
Address(Required)

Records requested and date(s) of service

Pathology and diagnostics lab reports, clinic/doctor’s notes, and all records pertaining to patient’s muscular dystrophy
From Start Date (or DOB if empty)
To End Date (or today's date if empty)
Purpose of this request: To obtain medical information for the Jain Foundation patient registry. Duration: Authorization is valid for one year from the date of signature or until (Add date)

Send Records To:

Jain Foundation Inc. 9706 4th Ave NE, Ste 101 Seattle, WA 98115 Fax: 425-658-1703 Phone: 425-882-1492 Email: patients@jain-foundation.org Web: www.jain-foundation.org
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