GREATER
CINCINNATI GASTROENTEROLOGY ASSOCIATES,
INC.
______
George D. Waissbluth, M.D. Kim Richard Jurell, M.D.
Michael
A. Safdi, M.D. FACP,
FACG Pradeep
Bekal, M.D.
Alan V. Safdi, M.D., FACG Mark E. Jonas, M.D.
Kris
Ramprasad, M.D. John P.
Czarnecki, M.D.
Lisa S. Lestina, M.D.
Date: ________________________________________________________________
I hereby authorize and request ____________________________________________
To release to ________________________________________________________
_______________________________________________________
_______________________________________________________
_______________________________________________________
copies of my medical records in your possession during the period of ______________
______________________________________________________________________
Name: ________________________________________________________
Date of Birth: ________________________________________________________
Address: ________________________________________________________
________________________________________________________
Signature: ________________________________________________________
Date Signed: ________________________________________________________