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<>BDC BT /TT2 1 Tf 9 0 0 9 117.1985 744.3896 Tm 0 Tc .0278 Tw [(\(For Of)17.6(ficial Use Only\))]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 572.625 Tm [(P)73.7(A)73.7(TIENT INFORMA)73.7(TION:)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 135.8746 572.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 36 559.625 Tm .0278 Tw (Patient Name:)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 90.5894 559.625 Tm 0 Tw (______________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 232.4082 559.625 Tm .0278 Tw [( Maiden Name: _____________ Birthdate: ___)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 415.5247 559.625 Tm 0 Tw (_)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 421.6702 559.625 Tm (/___)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 438.2136 559.625 Tm (_)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 444.3592 559.625 Tm .0278 Tw [(/____ Phone #:_______________)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 576 559.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7 0 0 7 36 551.625 Tm .0278 Tw [( Last Name, First Name, Middle Initial)]TJ ET EMC /P <>BDC BT 7 0 0 7 207.3529 551.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 36 538.625 Tm (Address:)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 71.6519 538.625 Tm (___________________________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 350.5623 538.625 Tm .0278 Tw [( City:___________________ State:____ Zip:__________ )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 580.7231 538.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 519.6249 Tm .0278 Tw [(MEDICAL)17.6( INFORMA)73.7(TION REQUESTED FROM: )]TJ ET EMC /P <>BDC BT 7.5 0 0 7.5 225.0487 519.6249 Tm (\(Check box or fill in information\))Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 341.5093 519.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 344.1071 519.6249 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 506.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 43.112 506.625 Tm .0278 Tw [( 海角原创 )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 178.4485 506.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 185.5605 506.625 Tm .0278 Tw [( Rush Oak Park Hospital )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 292.5582 506.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 299.6702 506.625 Tm .0278 Tw [( Copley Memorial Hospital)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 399.5812 506.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 493.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 43.112 493.625 Tm .0278 Tw [( Rush )54.7(Aurora Surgery Center )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 166.6572 493.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 173.7693 493.625 Tm .0278 Tw [( Rush Medical Group)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 254.3188 493.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 480.6249 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 43.112 480.6249 Tm .0278 Tw [( Individual or Organization)17.6(s Name: )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 181.9922 480.6249 Tm 0 Tw (____________________________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 465.6299 480.6249 Tm .0278 Tw [( Phone #:_______________)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 576 480.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 36 467.625 Tm (Address:)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 74.267 467.625 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 249.1769 467.625 Tm .0278 Tw [( City:___________________ State:____ Zip:__________ F)54.7(AX #:_______________)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 576 467.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 450.6249 Tm .0278 Tw [(RELEASE REQUESTED MEDICAL)17.6( INFORMA)73.7(TION T)17.6(O: )]TJ ET EMC /P <>BDC BT 7.5 0 0 7.5 254.4248 450.6249 Tm (\(Requestor may be billed unless it is a medical office for continuation of care\))Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 533.8574 450.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 437.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 43.112 437.625 Tm .0278 Tw [( Check box if same as patient information above )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 229.0293 437.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 36 424.625 Tm .0278 Tw [(Individual or Organization)17.6(s Name: )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 172.5376 424.625 Tm 0 Tw (______________________________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 465.6299 424.625 Tm .0278 Tw [( Phone #:_______________)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 576 424.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 36 411.625 Tm (Address:)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 74.267 411.625 Tm (_____________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 249.1769 411.625 Tm .0278 Tw [( City:___________________ State:____ Zip:__________ F)54.7(AX #:_______________)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 576 411.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 394.625 Tm (PURPOSE:)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 80.3967 394.625 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 36 381.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 43.5565 381.625 Tm .0278 Tw [( Continuation of Care )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 137.5804 381.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 145.137 381.625 Tm .0278 Tw [( For Personal Records )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 243.8674 381.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 251.4239 381.625 Tm .0278 Tw [( Insurance )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 304.339 381.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 311.8955 381.625 Tm .0278 Tw [( Legal )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 348.2796 381.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 355.8361 381.625 Tm .0278 Tw [( Other \(specify\): )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 419.9993 381.625 Tm 0 Tw (_________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 576 381.625 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 364.625 Tm .0278 Tw [(PREFERRED FORMA)73.7(T)110.8(:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 128.6363 364.625 Tm .0278 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 133.8318 364.625 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 141.3883 364.625 Tm .0278 Tw [( Paper)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8.5 0 0 8.5 166.668 364.625 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 170.918 364.625 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 176.1135 364.625 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 183.6699 364.625 Tm .0278 Tw [( CD)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8.5 0 0 8.5 198.5446 364.625 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 202.7946 364.625 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 207.99 364.625 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 215.5466 364.625 Tm .0278 Tw [( Fax to Number:__________________ )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 367.4779 364.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 375.0345 364.625 Tm .0278 Tw [( Secure Email address:)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 467.2723 364.625 Tm 0 Tw (_______________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 576.0818 364.625 Tm ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 8.5 0 0 8.5 133.75 351.625 Tm (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 138 351.625 Tm .0278 Tw [(If you choose Paper or CD: )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 252.0948 351.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 259.6513 351.625 Tm .0278 Tw [( Call Patient for Pick-up )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.5 0 0 8.5 359.8012 351.625 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 367.3577 351.625 Tm .0278 Tw [( Mail to Patient )54.7(Address )54.7(Above)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 483.8364 351.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 332.625 Tm .0278 Tw [(DA)73.7(TES: From____ /____ /____ T)73.7(o)0( ____ /____ /____)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 252.0936 332.625 Tm [(. \(See 揈f)17.6(fective paragraph on Page 2\))]TJ ET EMC /Artifact <>BDC 33.25 308.25 545.5 -95.5 re 404.319 332.625 m S EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 298.625 Tm (TYPE OF VISIT)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 96.4538 298.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 285.6249 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 285.6249 Tm (Inpatient )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 80.2074 285.6249 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 272.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 272.625 Tm .0278 Tw (Emergency Room )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 115.8588 272.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 259.6249 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 259.6249 Tm (Other )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 71.9993 259.6249 Tm (_________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 228.1061 259.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 71.9993 246.6249 Tm (_________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 576 246.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 71.9993 233.625 Tm (_________________________________)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 251 292.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 260 292.625 Tm (Outpatien)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 296.8596 292.625 Tm (t)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 300.1666 292.625 Tm (/)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 303.0009 292.625 Tm (Clinic: )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 330.2769 292.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 335 292.625 Tm [(Dr)54.7(./Dept. )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 371.7264 292.625 Tm (___________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 292.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 252.345 277.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 335 277.625 Tm (Location )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 371.4901 277.625 Tm (___________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 574.7638 277.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 577.3616 277.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 252.345 262.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 335 262.6249 Tm [(Dr)54.7(./Dept. )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 371.7264 262.6249 Tm (___________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 262.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 252.345 247.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 335 247.625 Tm (Location )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 371.4901 247.625 Tm (___________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 574.7638 247.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 577.3616 247.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 252.345 232.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 335 232.625 Tm [(Dr)54.7(./Dept. )]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 371.7264 232.625 Tm (___________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 232.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 252.345 217.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 335 217.625 Tm (Location )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 371.4901 217.625 Tm (___________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 574.7638 217.625 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 36 183.9999 Tm .0278 Tw [(STEP)17.6( 1 OF 3)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 84.0965 183.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 168 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 45 168 Tm .0278 Tw (Abstract Only )Tj ET EMC /P <>BDC BT 8 0 0 8 95.6829 168 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 158 Tm .0278 Tw [(\(Discharge Summary)73.7(, History)]TJ ET EMC /P <>BDC BT 8 0 0 8 149.3196 158 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 147.9999 Tm .0278 Tw [(& Physical, Of)17.6(fice/Progress)]TJ ET EMC /P <>BDC BT 8 0 0 8 142.2258 147.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 138 Tm .0278 Tw (Notes, Operative Reports,)Tj ET EMC /P <>BDC BT 8 0 0 8 137.929 138 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 128 Tm (ED)Tj /TT1 1 Tf 1.3892 0 TD <0001>Tj /TT2 1 Tf .2778 0 TD .0278 Tw (Notes, Pathology)Tj ET EMC /P <>BDC BT 8 0 0 8 119.484 128 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 117.9999 Tm .0278 Tw (Reports, Consults, EKGs,)Tj ET EMC /P <>BDC BT 8 0 0 8 136.5891 117.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 108 Tm .0278 Tw (Radiology Reports,)Tj ET EMC /P <>BDC BT 8 0 0 8 113.2574 108 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 97.9999 Tm .0278 Tw (Laboratory Reports\))Tj ET EMC /P <>BDC BT 8 0 0 8 116.3668 97.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 82.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 45 82.9999 Tm .0278 Tw (Entire Medical Record)Tj ET EMC /P <>BDC BT 8 0 0 8 124.1438 82.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 67.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 45 67.9999 Tm .0278 Tw (Other; Or in addition to)Tj ET EMC /P <>BDC BT 8 0 0 8 126.8188 67.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 45 58 Tm .0278 Tw (Abstract, select in Step 2)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 196.625 Tm [(REQUESTED MEDICAL)17.6( INFORMA)73.7(TION:)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 36 312.6249 Tm [(LOCA)73.7(TION OF RECORDS BEING REQUESTED:)]TJ ET EMC /Artifact <>BDC q 1 0 0 1 159 193 cm 0 0 m 0 -146 l S Q EMC /Artifact <>BDC q 1 0 0 1 387 193 cm 0 0 m 0 -146 l S Q EMC /P <>BDC BT 8 0 0 8 162 183.9999 Tm [(STEP)17.6( 2 OF 3 \(IF NEEDED\))]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 260.7637 183.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 168 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 168 Tm .0102 Tw [(Cardiac T)110.8(esting )-17.6(Result)]TJ ET EMC /P <>BDC BT 8 0 0 8 251.3391 168 Tm 0 Tw (s)Tj ET EMC /P <>BDC BT 8 0 0 8 255.7839 168 Tm (/)Tj ET EMC /P <>BDC BT 8 0 0 8 258.0066 168 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 171 158 Tm (EKG)Tj ET EMC /P <>BDC BT 8 0 0 8 187.8944 158 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 147.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 147.9999 Tm (Consultations)Tj ET EMC /P <>BDC BT 8 0 0 8 219.4727 147.9999 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 138 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 138 Tm .0278 Tw (Discharge Summary)Tj ET EMC /P <>BDC BT 8 0 0 8 243.6871 138 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 128 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 128 Tm .0278 Tw (Emergency Record)Tj ET EMC /P <>BDC BT 8 0 0 8 239.6949 128 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 117.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 117.9999 Tm (EM)Tj ET EMC /P <>BDC BT 8 0 0 8 183 117.9999 Tm .0556 Tc (G/)Tj ET EMC /P <>BDC BT 8 0 0 8 192.3351 117.9999 Tm 0 Tc .0278 Tw (EEG Reports)Tj ET EMC /P <>BDC BT 8 0 0 8 239.6863 117.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 108 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 108 Tm .0278 Tw (History & Physical)Tj ET EMC /P <>BDC BT 8 0 0 8 235.9055 108 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 97.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 97.9999 Tm .0278 Tw (Immunization Records)Tj ET EMC /P <>BDC BT 8 0 0 8 250.8083 97.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 87.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 171 87.9999 Tm .0278 Tw (Lab Reports)Tj ET EMC /P <>BDC BT 8 0 0 8 214.8043 87.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162 78 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 169.112 78 Tm .0278 Tw [( Mammography)]TJ ET EMC /P <>BDC BT 8 0 0 8 224.9085 78 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 162.1094 67.9999 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 171 67.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 178.112 67.9999 Tm .0278 Tw [( Films)]TJ ET EMC /P <>BDC BT 8 0 0 8 199.6624 67.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 162.04 58 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 171 58 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 178.112 58 Tm .0278 Tw [( Reports)]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 390 183.9999 Tm [(STEP)17.6( 3 OF 3 \(IF NEEDED\))]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 488.7636 183.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 429.26 168 Tm .0278 Tw [(ADDITIONAL)17.6( INFORMA)73.7(TION )]TJ ET EMC /P <>BDC BT 8 0 0 8 539.1849 168 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 445.7327 158 Tm .0278 Tw [(T)17.6(O)0( BE RELEASED)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8 0 0 8 516.2672 158 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8 0 0 8 520.2673 158 Tm ( )Tj ET EMC /P <>BDC BT 6.5 0 0 6.5 394.7909 147.9999 Tm .0278 Tw [(P)73.7(A)73.7(TIENT INITIAL)17.6( )36.6(AND DA)73.7(TE REQUIRED FOR EACH ITEM)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 571.2091 147.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 390 134 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 399 134 Tm .0102 Tw [(Genetic T)110.8(esting)]TJ ET EMC /P <>BDC BT 8 0 0 8 456.1093 134 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 465 134 Tm .0278 Tw (Initial:_______ Date:________ )Tj ET EMC /P <>BDC BT 8 0 0 8 576.6477 134 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 390 119 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 399 119 Tm (Dru)Tj ET EMC /P <>BDC BT 8 0 0 8 411.8906 119 Tm (g)Tj ET EMC /P <>BDC BT 8 0 0 8 416.7846 119 Tm (/Alcohol)Tj ET EMC /P <>BDC BT 8 0 0 8 447.2188 119 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 465 119 Tm .0278 Tw (Initial:_______ Date:________ )Tj ET EMC /P <>BDC BT 8 0 0 8 576.6477 119 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 390 103.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 399 103.9999 Tm (HIV)Tj ET EMC /P <>BDC BT 8 0 0 8 413.879 103.9999 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 465 103.9999 Tm .0278 Tw (Initial:_______ Date:________)Tj ET EMC /P <>BDC BT 8 0 0 8 574.2027 103.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 390 88.9999 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 399 88.9999 Tm .0278 Tw (Mental Health/)Tj ET EMC /P <>BDC BT 8 0 0 8 450.8044 88.9999 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 399 78.9999 Tm (Developmental)Tj ET EMC /P <>BDC BT 8 0 0 8 452.3633 78.9999 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 399 69 Tm (Disability)Tj ET EMC /P <>BDC BT 8 0 0 8 431.6602 69 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 465 69 Tm .0278 Tw (Initial:_______ Date:________ )Tj ET EMC /P <>BDC BT 8 0 0 8 576.6477 69 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 390 54 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 276 183.8159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 276 167.8159 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 285 167.8159 Tm .0278 Tw (Operative Reports)Tj ET EMC /P <>BDC BT 8 0 0 8 350.1403 167.8159 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 276 157.8159 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 285 157.8159 Tm .0278 Tw (Pathology Reports)Tj ET EMC /P <>BDC BT 8 0 0 8 351.0387 157.8159 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 276 147.8159 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 285 147.8159 Tm .0278 Tw [(Physician Of)17.6(fice Record)]TJ ET EMC /P <>BDC BT 8 0 0 8 370.6711 147.8159 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 276 137.8159 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 285 137.8159 Tm .0278 Tw (Progress Notes)Tj ET EMC /P <>BDC BT 8 0 0 8 340.3551 137.8159 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 276 127.8159 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 285 127.8159 Tm (Radiology)Tj ET EMC /P <>BDC BT 8 0 0 8 320.5781 127.8159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 276.1094 117.8159 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 285 117.8159 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 292.112 117.8159 Tm .0278 Tw [( Images)]TJ ET EMC /P <>BDC BT 8 0 0 8 320.7914 117.8159 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 276.0399 107.8159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 285 107.8159 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8 0 0 8 292.112 107.8159 Tm .0278 Tw [( Reports)]TJ ET EMC /P <>BDC BT 8 0 0 8 322.5687 107.8159 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8 0 0 8 276 96.8159 Tm (______________________)Tj ET EMC /P <>BDC BT 8 0 0 8 373.8828 96.8159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 276 85.816 Tm (______________________)Tj ET EMC /P <>BDC BT 8 0 0 8 373.8828 85.816 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 276 74.8159 Tm (______________________)Tj ET EMC /P <>BDC BT 8 0 0 8 373.8828 74.8159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 276 63.8159 Tm (______________________)Tj ET EMC /P <>BDC BT 8 0 0 8 373.8828 63.8159 Tm ( )Tj ET EMC /P <>BDC BT 8 0 0 8 276 52.816 Tm (______________________)Tj ET EMC /Artifact <>BDC q 1 0 0 1 33 181 cm 0 0 m 546 0 l S Q EMC Q endstream endobj 171 0 obj <>/XObject<>/ExtGState<>>> endobj 267 0 obj <> endobj 281 0 obj <>stream /Artifact <>BDC q 1 i 0 792 612 -792 re 306 396.015 m W n 0 792.015 612 -792 re W n 0 0 0 1 K 0 J 0 j 1.5 w 10 M [] 0 d /GS2 gs q 1 0 0 1 288 756 cm 0 0 m 0 -120 l S Q EMC /Artifact <>BDC q 1 0 0 1 36 636 cm 0 0 m 540 0 l S Q EMC /P <>BDC BT /TT4 1 Tf 12 0 0 12 327.9442 726 Tm 0 0 0 1 k 0 Tc .0278 Tw [(AUTHORIZA)73.7(TION FOR RELEASE OF )]TJ ET EMC /P <>BDC BT 12 0 0 12 539.7231 726 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 12 0 0 12 337.776 712.9999 Tm .0278 Tw [(P)73.7(A)73.7(TIENT HEAL)73.7(TH INFORMA)73.7(TION)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 36 619.875 Tm [(PLEASE READ THE FOLLOWING ST)73.7(A)73.7(TEMENTS CAREFULL)91.8(Y)73.7(:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 9.5 0 0 9.5 314.5917 619.875 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 603.625 Tm .0326 Tw [(This authorization is voluntary)73.7(. Rush will not condition your treatment on giving this authorization. However)54.7(, Rush may conditi)]TJ 55.7295 0 TD 0 Tw (on)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576.0002 603.625 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 593.3749 Tm .0278 Tw (the provision of research-related treatment on the provision of an authorization.)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 370.8011 593.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 577.125 Tm -.0009 Tw (I understand that I may change my mind and revoke this authorization at any time by giving written notice of my revocation to t)Tj 55.7297 0 TD 0 Tw (he)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576.0001 577.125 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 566.8749 Tm .0812 Tw [(contact of)17.6(fice listed above. I understand that revocation of this authorization will not af)17.6(fect action Rush took in reliance on)]TJ 54.9267 0 TD [( this)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9999 566.8749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 556.625 Tm .0278 Tw (authorization before Rush received my written notice of revocation.)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 319.0343 556.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 540.3749 Tm .1964 Tw (I authorize the use and/or disclosure of my Protected Health Information \(PHI\) as described above. I understand that this)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576.0005 540.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 530.1249 Tm .1047 Tw (authorization is voluntary and made to confirm my decision so Rush may use an)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 385.2939 530.1249 Tm 0 Tw (d)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 391.6341 530.1249 Tm .1047 Tw (/or disclose my PHI for a specific purpose. )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 579.6345 530.1249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 519.875 Tm -.0304 Tw (I understand that if the persons or organizations I authorized above to receive an)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 371.2943 519.875 Tm 0 Tw (d)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 377.6344 519.875 Tm -.0304 Tw (/or use the PHI described above are not subject)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9998 519.875 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 509.625 Tm .0281 Tw (to federal health information privacy laws, they may further disclose the PHI and it may no longer be protected by federal heal)Tj 56.0078 0 TD 0 Tw (th)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9998 509.625 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 499.3749 Tm .1048 Tw (information privacy laws. I understand that I have a right to inspect and copy the information to be disclosed pursuant to this)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576.0007 499.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 489.125 Tm .0278 Tw [(authorization and that I may obtain a copy of the information by contacting the of)17.6(fice listed above.)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 448.278 489.125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 472.875 Tm .0385 Tw (I have had full opportunity to read and consider the contents of this authorization, and I confirm that the contents are consis)Tj 55.1739 0 TD 0 Tw (tent)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576.0001 472.875 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 462.6249 Tm .0812 Tw (with my direction to Rush. I understand that, by signing this form, I am confirming my authorization that Rush may use and/or)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9994 462.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 452.375 Tm .0278 Tw (disclose to the persons and/or organizations named in this form the PHI described in this form.)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 436.5195 452.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 9.5 0 0 9.5 36 436.125 Tm .0806 Tw [(EFFECTIVE: This authorization request does not apply to any treatment dates beyond the date of signature. )17.6(Y)73.7(ou may)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9998 436.125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 425.875 Tm .1144 Tw (choose to provide an event \(related to you or the purpose of the us)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 352.5791 425.875 Tm 0 Tw (e)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 358.3908 425.875 Tm .1144 Tw (/disclosure\) upon which your authorization will)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576.0005 425.875 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 415.625 Tm .0697 Tw (expire, unless mental health records are requested. Otherwise, this authorization will expire ninety \(90\) calendar days)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9998 415.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 405.375 Tm .0278 Tw (after the date of signature.)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 156.3532 405.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 37.0883 389.125 Tm (______________________________________________________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576 389.125 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 37.0883 372.875 Tm (______________________________________________________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 576 372.875 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 356.6249 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 346.375 Tm [(P)73.7(A)73.7(TIEN)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 69.4356 346.375 Tm (T)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 75.7669 346.375 Tm (/)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 79.4628 346.375 Tm .0278 Tw [(PERSONAL)17.6( REPRESENT)73.7(A)73.7(TIVE扴 SIGNA)73.7(TURE:)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 289.9139 346.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 9.5 0 0 9.5 36 336.125 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 325.875 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36.2766 315.6249 Tm (___________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 349.6877 315.6249 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 384 315.6249 Tm (Date:)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 407.9138 315.6249 Tm (_________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 540 315.6249 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 305.375 Tm .0278 Tw (Signature of Patient or Personal Representative )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 241.4255 305.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 295.125 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 284.8749 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36.2766 274.625 Tm (___________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 349.6877 274.625 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 384 274.625 Tm .0278 Tw (Phone #:)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 423.7642 274.625 Tm 0 Tw (______________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 540 274.625 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 264.375 Tm .0278 Tw [(If signed by other than patient: PRINT)17.6( Representative Name)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 291.411 264.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 254.1249 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 243.875 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36.2766 233.625 Tm (___________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 348 233.625 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 223.3749 Tm .0278 Tw (If signed by other than patient: State Relationship to Patient )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 291.6096 223.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 213.125 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 202.875 Tm ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 9.5 0 0 9.5 36 192.6249 Tm (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 9.5 0 0 9.5 40.7263 192.6249 Tm -.0028 Tc .0916 Tw (\(Signature of a witness who has verified the patien)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 258.6287 192.6249 Tm 0 Tc 0 Tw (t)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 262.2983 192.6249 Tm (/)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 265.4396 192.6249 Tm -.0028 Tc .0916 Tw [(personal representative)17.6(s identity is required for genetic testing, HIV)91.8(, and)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9736 192.6249 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 182.375 Tm -.0028 Tc (dru)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 49.6514 182.375 Tm .0528 Tc (g/)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 58.5778 182.375 Tm -.0028 Tc -.0172 Tw [(alcohol records. )54.7(Additionally)73.7(, signature of )]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 231.2256 182.375 Tm 0 Tw (patient)Tj ET EMC /Artifact <>BDC .633 w q 1 0 0 1 231.226 181.325 cm 0 0 m 28.339 0 l S Q EMC /P <>BDC BT 9.5 0 0 9.5 259.5642 182.375 Tm -.0172 Tw [( is required for mental health records if over the age of 12 and under the age)]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 575.9739 182.375 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 172.125 Tm -.0028 Tc .0278 Tw (of 18.\))Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 63.0115 172.125 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 161.8749 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 151.625 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36.2766 141.375 Tm (___________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 349.6877 141.375 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 384 141.375 Tm (Date: )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 412.9333 141.375 Tm (________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 539.7361 141.375 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 542.6394 141.375 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 131.1249 Tm .0278 Tw (Witness Signature )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 116.2574 131.1249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 120.875 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 110.625 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36.2766 100.3749 Tm (___________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 349.6877 100.3749 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 384 100.3749 Tm .0278 Tw (Phone #:)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 423.7642 100.3749 Tm 0 Tw (______________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 540 100.3749 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 90.1249 Tm .0278 Tw [(PRINT)17.6( Witness Name )]TJ ET EMC /P <>BDC BT 9.5 0 0 9.5 132.1676 90.1249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 79.875 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 69.6249 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36.2766 59.3749 Tm (___________________________________________________________)Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 348 59.3749 Tm ( )Tj ET EMC /P <>BDC BT 9.5 0 0 9.5 36 49.125 Tm .0278 Tw (State Relationship to Patient)Tj ET EMC /P <>BDC BT 7 0 0 7 36 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