Alta Vista Urological Specialists
108 Legion Drive, Suite D
Las Vegas, NM 87701
505-454-4000
505-454-4004
Medical Records Release Authorization
I, ___________________________, hereby authorize and request the release of
medical information from Alta Vista Urological Specialists to Albuquerque Urology
Associates, P.A. Please include my complete medical record including radiological,
lab, and pathology reports. Also include all progress notes as well as procedural
and operative reports.
I understand that my express consent is required to release any health care
information relating to testing, diagnosis, and/or treatment for HIV (AIDS virus),
sexually transmitted disease, psychiatric disorders, mental health or drug or alcohol
use, you are specially authorized to release all health care information pertaining to
such diagnosis, testing or treatment.
Please have my records (choose one):
____ sent to Albuquerque Urology Associates, P.A.
c/o Dr. Aaron J. Geswaldo
610 Broadway Blvd, N.E.
Albuquerque, NM 87102
____ Copied and ready for pick-up
Please allow two weeks to process your request.
________________________ ______________________
Patient Name Social Security Number
________________________ ______________________
Address City, State, Zip
__________________________________________
Signature