Name *(Required) E-mail *(Required) Phone Number *(Required) Queries REQUEST FOR RECORDS DATE (mm/dd/yyyy) TO (DOCTOR/HOSPITAL) ADDRESS CITY STATE ZIP CODE I hereby authorize the release of my or copies of such and request that they be transferred to Dr. at 3500 Nostrand Avenue, Brooklyn, New York 11229. Fax #718-646-1911 : Phone# 718-769-2521. Date of Records (mm/dd/yyyy) Name of Patient To whom it may concern : I do hereby give Finally Health Medical Services/ Healthquest permission to take a copy of my valid driver's license or a picture identification for their office files and this information shall not be used in any way without my knowledge or consent. Enter Code Verification Code
