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Ohio Medical Records Release Form 2

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This form is provided by The University of Toledo to authorize the disclosure or release of one person's protected health information.

Ohio Medical Records Release Form 2
Ohio Medical Records Release Form 2
ANATOMICAL DONATION PROGRAM
MEDICAL RECORDS RELEASE FORM
I, __________________________________________________(“Donor”), have made a gift of
my body to The University of Toledo, College of Medicine for use by the University for
educational, research, and scientific purposes.
In order to increase the educational, research, and scientific value of such gift subsequent to my
death, I authorize and request any hospital or institution in which I was a patient at any time
within two years prior to my death, and any physician who at any time attended me within two
years prior to my death, to furnish any and all records concerning my case history, treatment, and
examination that I may have received. These records can be forwarded to:
Coordinator, Anatomical Donation Program
Department of Neurosciences
The University of Toledo, College of Medicine
Mail Stop #1007
3000 Arlington Avenue
Toledo, Ohio 43614-5804
I release, on behalf of my heirs and estate, any such physician, hospital or institution from any
and all responsibility or liability that may arise from complying with this authorization.
Ohio Medical Records Release Form 2
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