Document ZJ6DGbzJVexD8XOVzkXKOdydp

UTHORITY TQ RELEASE MEDICAL INF^-iMATlDM To: Doctor/Hospital Paul M. Quinlan, PhD. Address 380 Union Street West Springfield MA 01089 In Re Patient Known Oates oi Treatment May 7, 1927 Date oi Birth: You are hereby authorized to lumish and release to, & Barry 024-20-5478 Robinson Donovan Madden all records, (not emitted by known dates of treatment listed above) inducting but not fimited to findings, treatment, opinions and /or observations as to my condition. Please do not disclose anything to insurance adjusters or other persons without written authority trom me. (This information constitutes confidential and privileged communication.) Prior authorizations are hereby cancelled. This authority shall continue in force until revoked by me in writing. We respectfully request the following: ___ Itemized Bin (or services jsx. Medical Reports ___ Emergency Room Records ___ Complete Hospital Record ___ Hospital Record (without nurses notes) ___ Abstract of Hospital Record ___ Discharge Summary - ___ Reports ot and an notes of surgical procedures ___ Admission History and Examination ___ Consent Form(s) ___ X-Ray Reports ___ X-Ray films ___ Positive espies of v.*Ray Films ___ Laboratory Repons ___ All Incident reports ___ EKG's, EMG's, CAT Scans, and an other test results Complete office records inc. ad writings from any source Please attach your invoice for any photostating cost and include n with requested records. Thank you. Attorney. _____ Janjes H. Tourtelotte' Robinson Donovan Madden & Barry 1500 Main Street, Box 15609 Springfield, MA 01115 Telephone (413) 732-2301 9213Z XJCC 081128