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558.638 593.813 m S EMC /P <>BDC BT /TT2 1 Tf 9 0 0 9 117.1985 744.3896 Tm 0 Tc .0278 Tw [(\(For Of)17.6(ficial Use Only\))]TJ ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 576.8124 Tm [(INFORMACIN DEL)17.6( P)73.7(ACIENTE:)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 160.3696 576.8124 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 36 563.8125 Tm .0278 Tw (Nombre del paciente:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 119.1102 563.8125 Tm 0 Tw (___________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 279.6992 563.8125 Tm .0278 Tw [( Nombre de soltera: _______________ Fecha de nacimiento: ___)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 527.3686 563.8125 Tm 0 Tw (_)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 533.3332 563.8125 Tm (/___)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 549.3901 563.8125 Tm (_)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 555.3549 563.8125 Tm (/____)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 576 563.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 555.8124 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT 7 0 0 7 119.2045 555.8124 Tm 0 Tc .0278 Tw (Apellido, Nombre, Inicial del 2.o nombre)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 244.297 555.8124 Tm .0278 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 249.3397 555.8124 Tm 0 Tc ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 542.8125 Tm .0278 Tw (Nmero de telfono:_____________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 280.9775 542.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 529.8125 Tm (Direccin:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 74.7917 529.8125 Tm (_________________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 299.6163 529.8125 Tm .0278 Tw [( Ciudad:___________________ Estado:____ Cdigo postal:__________ )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 580.5842 529.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 513.8124 Tm .0278 Tw [(INFORMACIN MDICA)36.6( SOLICIT)73.7(ADA)36.6( POR: \(Marque el casillero o complete con la informacin\) )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 412.9536 513.8124 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 500.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 500.8125 Tm .0278 Tw [( ֱ )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 167.1263 500.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 174.4605 500.8125 Tm .0278 Tw [( Rush Oak Park Hospital )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 270.7472 500.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 278.0814 500.8125 Tm .0278 Tw [( Copley Memorial Hospital )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 380.0967 500.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 387.431 500.8125 Tm .0278 Tw [( Rush Copley Surgicenter )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 487.1663 500.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 494.5004 500.8125 Tm .0278 Tw [( Rush Medical Group)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 572.6809 500.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 487.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 487.8125 Tm .0278 Tw [( Nombre de individuo u organizacin: )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 183.7438 487.8125 Tm 0 Tw (______________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 394.8036 487.8125 Tm .0278 Tw [( Nmero de telfono:______________________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 487.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 474.8124 Tm (Direccin:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 72.7417 474.8124 Tm (____________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 201.2129 474.8124 Tm .0278 Tw [( Ciudad:___________________ Estado:____ Cdigo postal:__________ F)54.7(AX #:_______________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 474.8124 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 458.8125 Tm .0278 Tw [(DIVULGAR INFORMACIN MDICA)36.6( SOLICIT)73.7(ADA)36.6( )36.6(A: \(Se podra facturar al solicitante, a menos que se trate de un consultorio mdico )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 561.4066 458.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 448.8125 Tm .0278 Tw (para la continuacin de la atencin\))Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 177.4244 448.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 435.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 435.8125 Tm .0278 Tw [( Marque el casillero si coincide con la informacin del paciente anterior )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 307.0114 435.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 422.8125 Tm .0278 Tw (Nombre de individuo u organizacin: )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 174.5673 422.8125 Tm 0 Tw (________________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 394.8036 422.8125 Tm .0278 Tw [( Nmero de telfono:______________________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 422.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 409.8125 Tm (Direccin:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 72.7417 409.8125 Tm (____________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 201.2129 409.8125 Tm .0278 Tw [( Ciudad:___________________ Estado:____ Cdigo postal:__________ F)54.7(AX #:_______________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 576 409.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 393.8125 Tm (FINALIDAD:)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 83.1998 393.8125 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 380.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 380.8125 Tm .0278 Tw [( Continuacin de la atencin )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 155.9311 380.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 163.2654 380.8125 Tm .0278 Tw [( Para constancia personal )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 266.9078 380.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 274.2421 380.8125 Tm .0278 Tw [( Seguro mdico )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 340.0467 380.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 347.381 380.8125 Tm .0278 Tw [( Cuestiones legales )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 427.4058 380.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 434.74 380.8125 Tm .0278 Tw [( Otro \(especifique\): )]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 511.7644 380.8125 Tm 0 Tw (______________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 576 380.8125 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 364.8125 Tm .0278 Tw [(FORMA)73.7(T)17.6(O)0( DE PREFERENCIA:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 155.3302 364.8125 Tm .0278 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 160.3729 364.8125 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 167.7071 364.8125 Tm .0278 Tw [( Impreso)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8.25 0 0 8.25 200.03 364.8125 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 204.155 364.8125 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 209.1976 364.8125 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 216.5319 364.8125 Tm .0278 Tw [( CD)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 8.25 0 0 8.25 230.969 364.8125 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 235.094 364.8125 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 240.1367 364.8125 Tm 0 Tc ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 247.4709 364.8125 Tm .0278 Tw [( Fax a nmero:_________________________)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 418.3472 364.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 36 348.8125 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 43.3342 348.8125 Tm .0278 Tw [( Direccin de correo electrnico protegido:)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 199.7629 348.8125 Tm 0 Tw (__________________________________________________________________________________)Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 576 348.8125 Tm ( )Tj ET EMC /P <>BDC BT 8.25 0 0 8.25 36 335.8125 Tm .0278 Tc ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 8.25 0 0 8.25 61.2135 335.8125 Tm 0 Tc (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 65.3385 335.8125 Tm .0278 Tw [(Si seleccion impreso o CD: )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 179.9652 335.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 187.2996 335.8125 Tm .0278 Tw [( Llamar al paciente para pasar a buscar )]TJ ET EMC /P <>BDC BT /F1 1 Tf 8.25 0 0 8.25 349.4062 335.8125 Tm 0 Tw ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 356.7405 335.8125 Tm .0278 Tw [( Enviar a la direccin del paciente anterior)]TJ ET EMC /P <>BDC BT 8.25 0 0 8.25 511.9731 335.8125 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.25 0 0 8.25 36 316.8125 Tm .0278 Tw [(FECHAS: Del____ /____ /____ a ____ /____ /____)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.25 0 0 8.25 239.6351 316.8125 Tm [(. \(V)54.7(er prrafo de V)17.6(igencia en la pgina 2\))]TJ ET EMC /Artifact <>BDC 33.25 288.25 545.5 -83.5 re 399.774 316.812 m S EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 278.625 Tm [(TIPO DE VISIT)73.7(A:)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 102.4345 278.625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 265.6249 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 265.6249 Tm .0278 Tw (Paciente ingresado )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 120.6068 265.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 252.6249 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 252.6249 Tm .0278 Tw (Sala de emergencias )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 127.9236 252.6249 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 36 239.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 45 239.625 Tm (Otra )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 67.272 239.625 Tm (__________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 228.0038 239.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 67.272 226.625 Tm (__________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 576 226.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 67.272 213.6249 Tm (__________________________________)Tj ET EMC /P <>BDC BT /F1 1 Tf 8 0 0 8 251 274.625 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 8.5 0 0 8.5 260 274.625 Tm (Ambulatori)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 300.6282 274.625 Tm .1112 Tc (a/)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 309.6079 274.625 Tm 0 Tc (Consultorio: )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 274.625 Tm [(Dr)54.7(.)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 368.878 274.625 Tm (/)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 371.7123 274.625 Tm (Dept. )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 395.3629 274.625 Tm (______________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 274.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 261.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 261.6249 Tm (Sede )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 380.9447 261.6249 Tm (_________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 574.7638 261.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 577.3616 261.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 248.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 248.625 Tm [(Dr)54.7(.)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 368.878 248.625 Tm (/)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 371.7123 248.625 Tm (Dept. )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 395.3629 248.625 Tm (______________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 248.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 235.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 235.625 Tm (Sede )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 380.9447 235.625 Tm (_________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 574.7638 235.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 577.3616 235.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 222.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 222.6249 Tm [(Dr)54.7(.)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 368.878 222.6249 Tm (/)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 371.7123 222.6249 Tm (Dept. )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 395.3629 222.6249 Tm (______________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 575.0001 222.6249 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 251.7416 209.625 Tm ( )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 358.0123 209.625 Tm (Sede )Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 380.9447 209.625 Tm (_________________________________________)Tj ET EMC /P <>BDC BT 8.5 0 0 8.5 574.7638 209.625 Tm ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 7.5 0 0 7.5 36 181.3749 Tm .0278 Tw [(P)73.7(ASO 1 DE 3)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 82.3393 181.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 36 168.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 42.9164 168.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 168.375 Tm .0278 Tw (Resumen solamente)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 113.9938 168.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 159.375 Tm .0278 Tw (\(Resumen del alta, Historia)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 136.0793 159.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 150.375 Tm .0278 Tw (clnica y examen fsico, Notas)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 145.0401 150.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 141.375 Tm .0278 Tw (de consultori)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 87.7328 141.375 Tm .0556 Tc 0 Tw (o/)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 94.8218 141.375 Tm 0 Tc (progreso,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 126.5064 141.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 132.375 Tm .0278 Tw (Informes operativos, Notas del)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 147.3402 132.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 123.375 Tm .0278 Tw (Dept. de Emergencia, Informes)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 149.424 123.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 114.375 Tm .0278 Tw (de patologa, Consultas, ECG,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 146.9338 114.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 105.375 Tm .0278 Tw (Informes radiolgicos,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 118.5751 105.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 96.375 Tm .0278 Tw (Informes de laboratorio\))Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 125.0383 96.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 36 82.3749 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 42.9164 82.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 82.3749 Tm .0278 Tw (Expediente mdico completo)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 141.7229 82.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 36 68.3749 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 42.9164 68.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 68.3749 Tm .0278 Tw (Otro; o adems del Resumen,)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 145.8824 68.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 45 59.3749 Tm .0278 Tw (seccin en el paso 2)Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.5 0 0 8.5 36 193.625 Tm [(INFORMACIN MDICA)36.6( SOLICIT)73.7(ADA:)]TJ ET EMC /P <>BDC BT 8.5 0 0 8.5 36 292.625 Tm [(UBICACIN DE EXPEDIENTES SOLICIT)73.7(ADOS:)]TJ ET EMC /Artifact <>BDC q 1 0 0 1 159 190 cm 0 0 m 0 -144 l S Q EMC /Artifact <>BDC q 1 0 0 1 387 190 cm 0 0 m 0 -144 l S Q EMC /P <>BDC BT 7.5 0 0 7.5 162 181.3749 Tm [(P)73.7(ASO 2 DE 3 \(SI ES NECESARIO\))]TJ ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 281.8917 181.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 168.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 168.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 168.375 Tm .0278 Tw (Resultados de pruebas)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 248.5518 168.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 159.375 Tm (cardaca)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 199.766 159.375 Tm .0556 Tc (s/)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 206.4337 159.375 Tm 0 Tc (EKG)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 222.2723 159.375 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 150.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 150.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 150.375 Tm (Consultas)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 204.3509 150.375 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 141.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 141.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 141.375 Tm .0278 Tw (Resumen del alta)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 229.7834 141.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 132.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 132.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 132.375 Tm .0278 Tw (Expediente del )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 223.1221 132.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 123.375 Tm .0278 Tw (Dept. de Emergencia)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 241.8721 123.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 114.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 114.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 114.375 Tm .0278 Tw (Informes de EMG o EEG)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 254.7803 114.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 105.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 105.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 105.375 Tm .0278 Tw (Historia clnica y )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 228.3073 105.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 96.375 Tm .0278 Tw (examen fsico)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 217.4791 96.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 87.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 87.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 87.375 Tm .0278 Tw (Cartillas de vacunacin)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 248.9582 87.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 78.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 78.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 78.375 Tm .0278 Tw (Informes de laboratorio)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 248.5408 78.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 162 69.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 168.9163 69.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 171 69.375 Tm (Mamografa)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 211.016 69.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 162.665 60.375 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 171 60.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 177.6675 60.375 Tm .0278 Tw [( Pelculas)]TJ ET EMC /P <>BDC BT 7.5 0 0 7.5 210.3918 60.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 162.665 51.375 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 171 51.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 177.6675 51.375 Tm .0278 Tw [( Informes)]TJ ET EMC /P <>BDC BT /TT4 1 Tf 7.5 0 0 7.5 390 181.3749 Tm [(P)73.7(ASO 3 DE 3 \(SI ES NECESARIO\))]TJ ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 509.8917 181.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 7.5 0 0 7.5 393.6197 165.375 Tm .0278 Tw [(INFORMACIN )36.6(ADICIONAL)17.6( QUE SE DIVULGAR)]TJ ET EMC /P <>BDC BT /TT6 1 Tf 7.5 0 0 7.5 568.6303 165.375 Tm 0 Tw (*)Tj ET EMC /P <>BDC BT /TT4 1 Tf 7.5 0 0 7.5 572.3803 165.375 Tm ( )Tj ET EMC /P <>BDC BT 6.175 0 0 6.5 434.043 155.375 Tm .0278 Tw [(INICIAL)17.5( DEL)17.5( P)73.5(ACIENTE )17.5(Y)17.5( FECHA)]TJ ET EMC /P <>BDC BT 6.175 0 0 6.5 531.9612 155.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 6.175 0 0 6.5 437.1677 147.375 Tm .0278 Tw [(REQUERIDA)36.5( P)73.5(ARA)36.5( CADA)36.5( TEM)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 6.5 0 0 6.5 528.8343 147.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 390 131.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 396.9163 131.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 399 131.375 Tm .0278 Tw (Prueba gentica)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 454.5813 131.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 465 131.375 Tm .0278 Tw (Inicial:_______ Fecha:________ )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 576.3383 131.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 390 116.375 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 396.9163 116.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 399 116.375 Tm (Drogas/Alcohol )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 452.4975 116.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 465 116.375 Tm .0278 Tw (Inicial:_______ Fecha:________ )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 576.3383 116.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 390 101.3749 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 396.9163 101.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 399 101.3749 Tm (VIH)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 412.9065 101.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 465 101.3749 Tm .0278 Tw (Inicial:_______ Fecha:________)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 574.0463 101.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 390 86.3749 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 396.9163 86.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 399 86.3749 Tm .0278 Tw (Salud menta)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 441.319 86.3749 Tm 0 Tw (l)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 443.4023 86.3749 Tm (/ )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 447.7783 86.3749 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 399 76.3749 Tm .0278 Tw (Discapacidad del)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 456.3263 76.3749 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 399 66.375 Tm (Desarrollo)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 433.7439 66.375 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 465 66.375 Tm .0278 Tw (Inicial:_______ Fecha:________ )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 576.3383 66.375 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT6 1 Tf 7.5 0 0 7.5 390 51.375 Tm (*)Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 393.75 51.375 Tm .0278 Tw (Se requiere la firma de un testigo en la pgina 2.)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 557.6039 51.375 Tm 0 Tw ( )Tj ET EMC /Artifact <>BDC q 1 0 0 1 33 178 cm 0 0 m 546 0 l S Q EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 262.01 168.5158 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 268.9263 168.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 271.01 168.5158 Tm .0278 Tw (Informes operativos)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 337.0814 168.5158 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 262.01 158.5158 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 268.9263 158.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 271.01 158.5158 Tm .0278 Tw (Informes de patologa)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 343.9733 158.5158 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 262.01 148.5158 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 268.9263 148.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 271.01 148.5158 Tm .0278 Tw (Expediente de consultorio mdico )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 386.4969 148.5158 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 262.01 138.5158 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 268.9263 138.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 271.01 138.5158 Tm .0278 Tw (Notas de progreso)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 333.1296 138.5158 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 262.01 128.5157 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 268.9263 128.5157 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 271.01 128.5157 Tm (Radiologa)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 306.8694 128.5157 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 262.6751 119.5158 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 271.01 119.5158 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 277.6776 119.5158 Tm .0278 Tw [( Imgenes)]TJ ET EMC /P <>BDC BT 7.5 0 0 7.5 312.9066 119.5158 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 262.6751 110.5158 Tm ( )Tj ET EMC /P <>BDC BT /F1 1 Tf 7.5 0 0 7.5 271.01 110.5158 Tm ()Tj ET EMC /P <>BDC BT /TT2 1 Tf 7.5 0 0 7.5 277.6776 110.5158 Tm .0278 Tw [( Informes)]TJ ET EMC /P <>BDC BT 7.5 0 0 7.5 309.1456 110.5158 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 262.01 99.5158 Tm (_____________________________)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 382.9732 99.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 262.01 88.5158 Tm (_____________________________)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 382.9732 88.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 262.01 77.5158 Tm (_____________________________)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 382.9732 77.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 262.01 66.5158 Tm (_____________________________)Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 382.9732 66.5158 Tm ( )Tj ET EMC /P <>BDC BT 7.5 0 0 7.5 262.01 55.5158 Tm (_____________________________)Tj ET EMC Q endstream endobj 171 0 obj <>/XObject<>/ExtGState<>>> endobj 268 0 obj <> endobj 282 0 obj <>stream /Artifact <>BDC q 1 i 0 792 612 -792 re 306 396.015 m W n 0 792.015 612 -792 re W n 0 0 0 1 K 0 J 0 j 1.5 w 10 M [] 0 d /GS2 gs q 1 0 0 1 288 756 cm 0 0 m 0 -120 l S Q EMC /Artifact <>BDC q 1 0 0 1 36 636 cm 0 0 m 540 0 l S Q EMC /P <>BDC BT /TT4 1 Tf 10 0 0 10 292.3672 727.5 Tm 0 0 0 1 k 0 Tc .0278 Tw [(AUT)17.6(ORIZACIN P)73.7(ARA)36.6( DIVULGAR INFORMACIN MDICA)]TJ ET EMC /P <>BDC BT 10 0 0 10 571.6328 727.5 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.1 0 0 9 296.9334 714.4999 Tm .0278 Tw [(AUTHORIZA)73.7(TION FOR RELEASE OF P)73.7(A)73.7(TIENT HEAL)73.7(TH INFORMA)73.7(TION)]TJ ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 620.0625 Tm [(POR F)54.7(A)73.7(VOR LEA)36.6( )36.6(A)73.7(TENT)73.7(AMENTE LAS SIGUIENTES )36.6(AFIRMACIONES:)]TJ ET EMC /P <>BDC BT /TT2 1 Tf 8.9725 0 0 9.25 330.1561 620.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 604.0624 Tm .0807 Tw (Esta autorizacin es voluntaria. Rush no condicionar su tratamiento al otorgamiento de esta autorizacin. No obstante, Rush po)Tj 58.4614 0 TD 0 Tw (dra)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0272 604.0624 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 594.0625 Tm .0278 Tw (condicionar la provisin de tratamiento relacionado con investigaciones al otorgamiento de una autorizacin.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 469.9536 594.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 578.0625 Tm .0092 Tw (Entiendo que puedo cambiar de opinin y dejar sin efecto esta autorizacin en cualquier momento por medio de un aviso por escri)Tj 57.9511 0 TD (to de)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0269 578.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 568.0625 Tm -.001 Tw (mi revocacin a la oficina de contacto mencionada anteriormente. Entiendo que la revocacin de esta autorizacin no afectar la)Tj 57.017 0 TD -.0001 Tc -.0009 Tw ( accin)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0271 568.0625 Tm 0 Tc 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 558.0624 Tm .0278 Tw (tomada por Rush en funcin de esta autorizacin antes de que Rush recibiera mi aviso por escrito de revocacin.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 491.3792 558.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 542.0625 Tm .2153 Tw (Autorizo el uso y/o divulgacin de mi Informacin de Salud Protegida \(PHI\) como se describe anteriormente. Entiendo que esta)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0262 542.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 532.0625 Tm -.0057 Tw (autorizacin es voluntaria y con ella confirmo mi decisin para que Rush pueda usar y/o divulgar mi PHI para un fin especfico.)Tj 55.9646 0 TD [( Entiendo)]TJ ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0266 532.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 522.0624 Tm .1237 Tw (que, si los individuos u organizaciones que autoric arriba a recibir y/o usar la PHI descrita anteriormente no estn sujetos a)Tj 57.4484 0 TD [( leyes)]TJ ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0264 522.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 512.0624 Tm .0455 Tw (federales de privacidad de la informacin de salud, pueden divulgar a otros la PHI, la cual es posible que ya no est protegida)Tj 56.8142 0 TD [( por las)]TJ ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0265 512.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 502.0625 Tm .007 Tw (leyes federales de privacidad de informacin de salud. Entiendo que tengo derecho a revisar y copiar la informacin que se divu)Tj 56.8968 0 TD (lgue de)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0265 502.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 492.0624 Tm .0278 Tw (acuerdo con esta autorizacin y que puedo obtener una copia de la informacin al contactar el consultorio mencionado anteriorme)Tj 58.2026 0 TD 0 Tw (nte.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 573.2094 492.0624 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 476.0625 Tm .0043 Tw (He tenido la plena oportunidad de leer y considerar los contenidos de esta autorizacin y confirmo que los contenidos estn de )Tj 56.5707 0 TD 0 Tw (acuerdo)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0269 476.0625 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 466.0625 Tm .0299 Tw (con mis indicaciones a Rush. Entiendo que, al firmar este documento, confirmo mi autorizacin para que Rush pueda usar y/o divu)Tj 58.517 0 TD 0 Tw (lgar)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0267 466.0625 Tm ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 456.0624 Tm .0278 Tw (a las personas u organizaciones nombradas en este formulario la PHI descrita aqu.)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 372.6711 456.0624 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT /TT4 1 Tf 8.9725 0 0 9.25 36.0189 440.0625 Tm -.021 Tw (VIGENCIA: Esta solicitud de autorizacin no se aplica a ninguna fecha de tratamiento fuera de la fecha de la firma. Usted puede)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0264 440.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 430.0625 Tm .1917 Tw (optar por proporcionar un evento \(relacionado con usted o el propsito del us)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 390.1683 430.0625 Tm .0556 Tc 0 Tw (o/)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 399.1398 430.0625 Tm 0 Tc .1917 Tw (revelacin\) a partir del cual expirar su)Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 576.0261 430.0625 Tm 0 Tw ( )Tj ET EMC /P <>BDC BT 8.9725 0 0 9.25 36.0189 420.0625 Tm .085 Tw (autorizacin, a menos que se soliciten expedientes de salud mental. 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