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I hereby authorize CHESTNUT HILL CARDIOLOGY, LTD. to release to the insurance companies indicated below information concerning my illness and treatments. I also autorize payment of medical benefits to the above named physician or group for medical services rendered to myself or my dependents. I understand that I am responsible for any amount not covered by my insurance.
INSURANCE CARRIER: INSURANCE CARRIER: Signature of insured: Date:
I authorize my medical records to be forwarded to the following physicians participating in my care: Referring Physician: Family Physician: Others:
Authorization is given to Chestnut Hill Cardiology to retireve lab results and test results from the facilities where these tests were performed.
I authorize confirmation of my appointments at the following telephone # I also give authorization to leave phone messages on my answering machine or with members of my family who answer the phone.
Signature: Date:
