Uploaded by Deepika Arora

ROI

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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: [email protected]
• 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: [email protected]
Mediclinic Ibn Battuta has no obligation / responsibility to the reports given to the authorized person
MC.ME.C.F.ADMIN.19.0