John J. Park M.D, Slawomir J. Marecik M.D, Kunal Kochar M.D.
1550 N. Northwest Highway, Suite 107 Park Ridge, IL 60068 Phone: (847)759-1110 Ext: 229 Fax: (847)759-8273
Authorization for Release of Confidential Health Information
I, Name of Patient or Authorized Agent* hereby authorize LM Prasad MD SC to release to: Name of Health Care Facility, Physician, Agency, etc.* Street Address* City* State* Zip* the following information contained in the patient record of Patient's Name* born Date* residing at Street Address* City* State* Zip* :
The above information for the following period of time shall be released from Date* to Date*