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Actived: 4 days ago

REQUEST FROM LAW ENFORCEMENT FOR RELEASE OF …

WEBPatient’s Name (if known): _____ Date: _____ Requestor’s Name: _____ Title/ID#: _____ Agency Name: _____ Phone Number: _____

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Carle Outside Referral Forms

WEB808 North Country Fair Drive Champaign, IL 61821 (217) 398-8000

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INFORMED CONSENT FOR SURGERY AND/OR PROCEDURES …

WEBI have had the opportunity to ask questions which have been answered to my satisfaction and agree to proceed. CONSENT FOR TREATMENT. Signature of Patient or …

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Authorization to Release Protected Health Information

WEBA separate special authorization must be completed to release mental health records. • I have the right to inspect and obtain a copy of the records that are to be disclosed (CFR …

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Authorization to Release Protected Health Information

WEBAuthorization to Release Protected Health Information X3864-0223 ROI Request for Imaging Today’s Date: Date needed: A.M./P.M. Return this completed form to: Carle …

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Carle Foundation Hospital INFORMED CONSENT FOR Carle …

WEBPROCEDURE(S) I authorize Dr. , and other personnel as he/she may deem necessary to perform the following surgical, medical

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INFORMED CONSENT FOR ASPIRATION AND/OR INJECTION …

WEBPROCEDURE(S) I authorize to perform the following procedure(s) on me for the treatment of my current medical condition, and I voluntarily

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Authorization To Release Information

WEBUse this side if multiple parties are being requested to release or receive medical information. I authorize the following parties/agencies to release and/or receive (as the …

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Carle Foundation Hospital Carle Physician Group Carle …

WEBPROCEDURE(S): I authorize Dr. _____, to perform the following surgical, medical and/or diagnostic procedures on me, and I voluntarily consent to and authorize these …

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AUTHORIZATION TO RELEASE PROTECTED HEALTH …

WEBAUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION 174-0619 ROI Patient Name: Date of Birth:

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CARLE HEALTH & AFFILIATE PRIVACY NOTICE

WEBcarle health & affiliate privacy notice this notice describes how medical information about you may be used and disclosed and how you can get access to this

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X1751 Authorized Relative Certification

WEBAUTHORIZED RELATIVE CERTIFICATION. (A certified copy of the death certificate must be attached.) certify that to the best of my knowledge and belief that no executor or …

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x HVI INFORMED CONSENT FOR PERICARDIOCENTESIS

WEBCONSENT FOR TREATMENT Signature of Patient or Authorized Person Date Time Signature of Witness Date Time I have discussed the proposed procedure, risks, …

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imprint Important Message from Medicare

WEBForm CMS 10065-IM (Exp. 12/31/2025) OMB approval 0938-1019 How to Ask For an Appeal of your Hospital Discharge • You must make your request to the QIO listed above.

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INFORMED CONSENT FOR THORACOSCOPY X2049-0519 …

WEBo Carle Foundation Hospital o Carle Physician Group o Carle SurgiCenter

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Patient Instructions Laboratory Hours of Operation

WEBX1864-0221 Patient Instructions Laboratory Hours of Operation Laboratory and Pathology Services Specimens collected outside the Laboratory must be returned to one of these …

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