AUTHORIZATION TO OBTAIN OR RELEASE OF MEDICAL RECORDS FROM MEDICAL PROVIDERS

I hereby authorize Glendale Internal Medicine and Cardiology Medical Group, INC (the Practice) to obtain any and all medical records concerning my care from any physician, hospital, or other health care professional that has provided medical care to me in the past. I also authorize the Practice to release any and all medical records concerning my care to any physician, hospital or other health care professional providing care to me at any time. Additionally, I authorize the Practice to release any and all medical records concerning my care to Medicare, Medicaid, or any insurance company, third party administrator, or managed care company.
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Cardiac Specialty Care

• Structural Heart Disease
• TAVR
• CardioMEMS (Heart Failure)
• PFO Closure

• Coronary Intervention
• Complex Higher-Risk (And Indicated) Patients (CHIP) Angioplasty
• Atherectomy
• Impella and ECMO Support

• Peripheral Angioplasty
• Varicose Vein Treatment (Venous Ablation)
• DVT thrombectomy - IVC filter
• Carotid Stenting

• Rhythm Management
• Pacemaker
• Holter Monitoring
• Exercise Stress Test
• Echocardiography
• Nuclear Stress Test
• Enhanced External Counterpulsation (EECP)

Medical Records Form

AUTHORIZATION TO OBTAIN OR RELEASE OF MEDICAL RECORDS FROM MEDICAL PROVIDERS

Cardiac Specialty Care