Ph.D., M.A.
Dental Research
D.D.S.
Dental Medicine
D.M.D., M.B.S.
D.D.S., M.S.
Dental
D.M.D., M.S.
D.M.D.
D.M.D., M.Ed.
D.D.S., MSD
D.M.D.. M.Ed., M.S.
D.D.S., M.A.G.D., F.I.C.D
D.D.S., F.A.G.D.
D.D.S, M.S.
D.D.S, M.B.A., MHSM, FICD
D.D.S., M.S.D.
D.D.S
D.M.D., F.A.G.D.
D.D.S., F.A.C.D.
D.D.S., M.H.A.Ed., B.S., D.H.
Ph.D.
B.D.S., D.M.D.
B.D.S, D.D.S., MDSc
D.D.S., M.A -Ed
D.M.D., M.Ed
D.M.D., R.D.H.
D.M.D., B.D.S.
D.D.S., F.A.G.D., F.A.C.D.
D.D.S., M.Ed.
MD
Family Medicine / Primary Care
DO
Family Medicine /Primary Care
Family Medicine/Primary Care
PhD
Psychology
OD, FAAO
O.D.
OD, MS
OD, FAAO, FSLS
OD, FAAO, FCOVD
Pediatrics
MD, FACS
OD, MS, FAAO
O.D., FAAO
OD, Ph.D, FAAO
Primary Care
D.O.
Family Medicine
D.P.M., FACFAS
Foot and Ankle
Osteopathic Manipulative Med
D.P.M., AACFAS
D.O., M.B.A., FACOOG
Women's and Children's Health
D.O., M.S., FACOFP
D.P.M., M.S.
D.O., AOBFP
D.O., FACOFP
D.N.P.
M.S., CCC-SLP
Speech-Language Pathology
Ph.D., CCC-SLP
PT, DPT, GCS
Physical Therapy
Ph.D., M.A., CCC-SLP
PT, DPT, OCS, FAAOMPT
PT, DPT, MSCI, CCI
MOT, OTR/L
Occupational Therapy
M.A., CCC-SLP
This authorization will expire 1 year from 12/07/2023.
I understand I may withdraw my authorization at any time by submitting a written request to the HIPAA Privacy Officer. I understand any revocation is not effective to the extent action has already been taken in reliance on this authorization. I understand information used or disclosed pursuant to this authorization may be subject to re-disclosure and may no longer be protected by federal or state law. This authorization is not intended to affect a patient's ability to receive medical care.
Alcohol and Drug Abuse Treatment. To the extent my medical record contains information regarding alcohol or drug treatment that is protected by federal law, I authorize the disclosure of such information or record.
HIV / AIDS Information To the extent my medical record contains information regarding my HIV/AIDS status, treatment or testing, I authorize the disclosure of such information or record.
Behavioral Health Notes / Record I authorize the disclosure of any behavioral health notes or information in my medical record.
With my digital signature below, I consent to the release of the above listed information / documents.
Community Partner site to email this completed form to communitypartners@midwestern.edu. Midwestern will contact the patient to schedule an appointment within 48 business hours of receipt.
