Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Para su conveniencia, debajo del texto en español le brindamos la versión completa de este formulario en inglés.
For your convenience, the complete English version of this form is attached below the Spanish version.
Medical Information Authorization Without In Suffolk - Authority for Release of Medical Information
Category:
State:
Multi-State
County:
Suffolk
Control #:
US-00426
Format:
Word
Instant download
Description
Free preview
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The Authorization of Health Release Form enables family, friends, or others to obtain health information relating to individuals in custody. I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form:.You can request, download, and access your medical record right to your smart phone or computer, through NYU Langone Health MyChart, our secure patient portal. This notice briefly describes how medical information about you may be used and shared and how you can get access to this information. On the top Enter your information where the boxes ask for Patient Name, Date of. Birth, Social Security Number and Patient Address.