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920010 Patient Label 8200 Dodge Street Omaha NE 68114 Phone 402 955-3800 Fax 402 955-7193 AUTHORIZATION TO RELEASE HEALTH INFORMATION I hereby authorize Children s Hospital Medical Center to release the following information Patient Name Date of Birth Address Telephone State City Zip Code To date Dates of Service From date Information to be released Hospital Records Primary Documents- Physician Reports/Diagnostic Tests OR Emergency/Urgent Care Report Discharge Summary Radiology Report Lab...
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8200 Dodge Street is a specific address located in Omaha, Nebraska.
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