Medical Release of Information for Ian
Anderson House
Please print this form and fax to: (905) 337-8006
DR._______________________
__________________________
__________________________
__________________________
Dear Dr. ___________________
I have applied for admission as a resident to Ian Anderson House, a provider of palliative care for those with terminal cancer.
I hereby authorize and direct you, as my physician, to release any medical information about my health as and when requested by Ian Anderson House.
The information you provide will assist in establishing my eligibility and suitability for residency at Ian Anderson House.
Please be as specific as possible about my health status and associated needs as this information will/may greatly assist the care-givers at Ian Anderson House in their assessment of my application for admission. Your report will remain confidential.
_____________________ Witness |
_____________________ Signature of Patient |
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_____________________ Print Name of Patient |
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Date:_________________ |