Authorization For Release of Medical Information

Authorization For Release of Medical Information
By submission of this form, I authorize MedRetreat to act as my medical travel agent as described below.
Authorization	I hereby assign MedRetreat as my medical travel agent to collect and disseminate my personal medical documentation for the purpose of receiving healthcare abroad. These documents will include: Diagnostic Imaging Reports/X-Rays/Photos History & Physical Exams Hospital/Doctor Charts Consultations Laboratory Reports Radiology Reports Operative Reports Discharge Summary Progress Notes Quotations/Billing Statements I understand that MedRetreat will protect and keep this information confidential to the best of their ability.
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I accept