| Northwest Cardiovascular Center Release of Medical Records From: _______________________________
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I, ____________________________ DOB:________, give permission to transfer my medical records to: Miroslaw Sochanski, M.D., F.A.C.C., F.S.C.A.I 3115 N. Harlem Ave. Chicago, IL 60634 Ph: 773-622-5200 Fax: 773-889-6571
5528 N. Milwaukee Ave. Chicago, IL 60630 Ph: 773-631-2015 Fax: 773-631-2015 Please include all records from ______________ to ____________, especially ______________________________.
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