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Request Information FROM

Request Information FROM

Authorization

I authorize Estrella Gastroenterology at the above address to request my information from the listed physicians/facilities. This information is for the treating specialist and should not be used for any other purpose. I understand that I may withdraw this consent at any time in writing except to the extent that action has been taken in reliance on it. This consent will last while I am being treated by Estrella Gastroenterology unless I withdraw my consent during treatment. This consent will expire 365 days after my last visit date, unless Estrella Gastroenterology is otherwise notified by me.

Request Information FROM:

By electronically signing below, I attest that I am the patient (or I am legally able to sign on behalf of the patient.) I authorize Estrella Gastroenterology to request the indicated information and receive it from the indicated parties. I understand that any fees that are assessed are to be paid by myself and are not the responsibility of Estrella Gastroenterology.

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