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The Fellowship
Jon Cherney
Boyd Lumsden
Scott Olvey
Joseph Cullen
Column 2
Nathan Van Zeeland
Matthew Butler
Blake Hildahl
Shawn Hennigan
David Toivonen (Retired)
Specialties
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Wrist
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Shoulder
Sports Injuries
Column 2
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Traumatic Orthopedic Injuries
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Column 1
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Meet Our Therapists
Column 2
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Before Your Surgery
Column 2
Day of Surgery
After Your Surgery
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Column 2
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Column 2
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Registration Form
Make An Appointment
Make A Payment
Physicians
Our Physicians
Column 1
The Fellowship
Jon Cherney
Boyd Lumsden
Scott Olvey
Joseph Cullen
Column 2
Nathan Van Zeeland
Matthew Butler
Blake Hildahl
Shawn Hennigan
David Toivonen (Retired)
Specialties
Specialties
Column 1
Hand
Wrist
Elbow
Shoulder
Sports Injuries
Column 2
Pediatric Conditions
Traumatic Orthopedic Injuries
Work Related Injuries
Psychological Services
Therapy
Our Therapy Center
Column 1
Orthopedic Rehabilitation Therapy Center
Meet Our Therapists
Column 2
Orthopedic/Family Physician Referral
Therapy Cash Pay Services
Podcast
Surgical Center
Our Surgical Center
Column 1
Woodland Surgery Center
Before Your Surgery
Column 2
Day of Surgery
After Your Surgery
Resources
Patient Resources
Column 1
Forms
Locations and Maps
Make an Appointment
Make a Payment
Column 2
Patient Portal
Patient Testimonials
Share Your Experience
Surgical Privileges and Locations
FAQ
FAQ
Column 1
Appointments and Referrals
Insurance and Billing
Cash Pay Services
Medical Records
Worker’s Compensation and 2nd Opinion
Surgery
Column 2
Third Party Liability
Employment
Mission Statement
Privacy Policy
Disclaimer
Release of Medical Information to Another Facility Form
Release of Medical Information to Another Facility Form
Last Name
*
First Name
*
MI
*
Date of Birth
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Address
*
Address
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Authorize Records Released To:
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City
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District of Columbia
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Records To Be Released From Dates Of Service
*
From Date
To:
*
To Date
Records To Be Released:
*
Office Notes
Operative Reports
Return to Work Slips
Laboratory Results (EMG, Radiology Reports, etc.)
Therapy Notes
X-ray Disks
Other
Other
Purpose For Release:
*
Release Records From:
*
Jon J. Cherney, M.D.
Boyd C. Lumsden, M.D.
Scott P. Olvey, M.D.
Joseph P. Cullen, M.D.
Nathan L. Van Zeeland, M.D.
Matthew A. Butler, M.D.
Shawn P. Hennigan, M.D.
Blake W. Hildahl, M.D., ATC
Digital Signature of Patient
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If signed by person other than patient, state relationship:
Date
This authorization will expire one year from signature date. I understand that I may revoke this authorization at any time by providing my written revocation. This release is executed in conformity with Wis. Stats. §§146.81-83, 51.30, 252.15 and 102.13.
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