… Fax this completed form to Neurosciences Schedulers Fax (608) 775-5263 Records must accompany this referral. Please include documentation, such as: imaging … to referral reason; lab results; current medications; allergies; etc. Fax Medical records to Health Information Management/Medical Records (608) 775-4706 Appointment request o Pain Medicine (Imaging and Imaging …

… Number: Fax Number: INFORMATION TO BE DISCLOSED AND DATE OF SERVICE: ¨ All Clinic Records ¨ Other Facility Records ¨ Discharge Summary ¨ History & Physical ¨ Surgical Report ¨ Lab Reports ¨ … permission to release otherwise highly confidential information, please release records pertaining to: (please check all that apply) ¨ Mental Health ¨ Developmental …

…     This assessment includes primary data from communicable disease reports, death records, local  …

…     This assessment includes primary data from communicable disease reports, death records, local  …

… and other care offerings Improving Patient Advocacy Without easy access to health records, proactive action on the patients end in their care can be difficult Utilize … information and tools Offer training and promotion of EPIC Electronic Health Records System’s capabilities that will be implemented in 2015 Promoting access to …

… and other care offerings Improving Patient Advocacy Without easy access to health records, proactive action on the patients end in their care can be difficult Utilize … information and tools Offer training and promotion of EPIC Electronic Health Records System’s capabilities that will be implemented in 2015 Promoting access to …

… the Patient Right to Restrict Protected Health Information to Health Plan form. The records of the restricted services/items listed below will not be released or billed … Department, mailstop AVS-001(ROI) HIM Dept. will scan into patient’s medical records under doc type: Release of Information. If Approved - HIM Dept. will add …

… my insurer(s) to share my past, current and future health, treatment, and account records about services I’ve received from Gundersen and other care providers as … the right to inspect and receive a copy of the material to be disclosed. Copies of records may be obtained with reasonable notice and payment of copying cost. • If the …

… my insurer(s) to share my past, current and future health, treatment, and account records about services I’ve received from Gundersen and other care providers as … the right to inspect and receive a copy of the material to be disclosed. Copies of records may be obtained with reasonable notice and payment of copying cost. • If the …

… Restroom Founders Elevators Link Elevator East Elevators Adolf’s Grille Medical RecordsTo GundersenHotel & Suites Imaging Services East • MRI • PET Scan • X-ray to …

… 1900s. More recently, the health system used the building to house paper medical records. With walls as thick as 52 inches on some floors and a sound structure, …

… 1900s. More recently, the health system used the building to house paper medical records. With walls as thick as 52 inches on some floors and a sound structure, …

… issues dealing with cyberbullying, give Justin advice not to retaliate and keep records of the harassment. The counselor might also offer to talk with Justin’s …

… explaining the procedure, ADMINISTER the radiopharmaceutical to the patient. This records the date and time. When the patient arrives, Select the patient you will be …

… EMG ORDER FORM Please fax this form and medical records to (608) 775-5263 Order date: __________________________ Ordering provider …

… reserves the right to cancel an exhibit. Please keep this list of criteria for your records and complete the application form on the next page. Exhibiting 1. The …