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Release of Medical Records Form

AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

ATTORNEY
Kindly furnish any and all of my records and information to my attorney . This information includes but is not limited to my history obtained, x-ray, MRI, physical findings, any diagnostic tests, diagnosis and prognosis. I am authorizing this office to provide this information in accordance with Federal HIPAA rule and New York State Law.

DOCTOR
Kindly furnish any and all of my records and information to my doctor . This information includes but is not limited to my history obtained, x-ray, MRI, physical findings, any diagnostic tests, diagnosis and prognosis. I am authorizing this office to provide this information in accordance with Federal HIPAA rule and New York State Law.

FAMILY MEMBER/ FRIEND
Kindly furnish any and all of my records and information to my . This information includes but is not limited to my history obtained, x-ray, MRI, physical findings, any diagnostic tests, diagnosis and prognosis. I am authorizing this office to provide this information in accordance with Federal HIPAA rule and New York State Law.

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