West Park Medical Group Individual Records Release Authorization (Page 3 of 3) in pdf

West Park Medical Group Individual Records Release Authorization Page 3

please write to Arlene Beharry (Privacy Officer) 1886 Broadway, 2

Floor, New York, N.Y.

10023.

SIGNATURE

I have read this form and all of my questions about this form have been answered. By signing

below, I acknowledge that I have read and accept all of the above.

______________________________________________

Signature of Patient or Patient’s Personal Representative

_______________________________________________

Print Name of Patient or Patient’s Personal Representative

_______________________________________________

Date

_______________________________________________

Description of Personal Representative’s Authority

CONTACT INFORMATION

The contact information of the patient or personal representative who signed this form should be

filled in below.

Address:

Telephone:

______________________________

______________________

(Daytime)

______________________________

______________________

(Evening)

______________________________

Email Address (optional):

______________________________

______________________

THE PATIENT OR HIS OR HER PERSONAL REPRESENTATIVE

MUST BE PROVIDED WTH ACOPY OF THIS FORM AFTER IT HAS BEEN SIGNED.

West Park Medical Group

INDIVIDUAL AUTHORIZATION FORM

Effective 4/4/03

West Park Medical Group Individual Records Release Authorization Page 3