Release of Medical Information Request / Authorization Form I (Patient Name) PIN Date of Birth Contact No. authorize Mediclinic Ibn Battuta to release information to (Name of person or organization if different from above named patient) Contact No. Address The release of medical information shall be done via Mail Person Email Fax Other *Reports will only be released in English. Please ensure completion of all fields, submission of incomplete form will result in a delay of issuance of medical records. Visit date - Mediclinic Ibn Battuta Doctor’s Name Type of information to be disclosed (please check all that apply) Laboratory reports Discharge Summary (Maximum 3 working days from date of discharge) Please specify Radiology reports (X-Ray, Ultra Sound, CT, MRI Reports) Others Please specify Please specify Note: Written medical reports by doctors for OPD / A&E consultation will be charged and will take maximum of 5 working days. Reason for request I understand that I may revoke this authorization at any time by written notification to Mediclinic Ibn Battuta following this date, except for the information. which may have been released prior to the revocation. This consent form will be e ective untill the end of the specified year, unless otherwise specified. Signature Date Patient or person giving consent (name printed) The signature is of the Patient Parent of Minor Legal guardian Patient’s next of kin Person authorized by patient Relationship to patient, if any • Complete the form signed by the patient and hand it over in main reception or fax it to MRD +971 4 440 8000 or e-mail to: liju.joseph@mediclinic.ae • Medical record department staff will call and inform you once the report is ready and if any delay in process • For further clarification - contact MRD, Tel +971 4 440 9000 Fax +971 4 440 8000 or e-mail to: liju.joseph@mediclinic.ae Mediclinic Ibn Battuta has no obligation / responsibility to the reports given to the authorized person MC.ME.C.F.ADMIN.19.0