I, or my authorized representative, request that health information regarding my care and treatment as set forth on this form:
In accordance with New York State Law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I understand that:
9(a). Specific information to be released:
n Entire Medical Record, including patient histories, office notes (except psychotherapy notes), test results, radiology studies, films, referrals, consults, billing records, insurance records, and records sent to you by other health care providers.
Authorization to Discuss Health Information
Initials Name of individual health care provider
to discuss my health information with my attorney, or a governmental agency, listed here: (Attorney/Firm or Governmental Agency Name)
10. Reason for release of information:
All Items on this form have been completed and my questions about this form have been answered. In addition, I have been provided a copy of the form.
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