Authorization of Release of Records to Third Party
Please correct the errors described below.
, hereby authorize New Orleans Podiatry Associates and its affiliated agents to release my medical records, or the medical records of my minor child
(name of minor)
or a person for whom I have power of attorney
(name of person)
in their entirety to
(name of third party recipient of medical records)
This includes but is not limited to physician progress notes, operative reports, radiology reports, laboratory results, and any external or internal information that has been created or collected on my behalf
Third Party Contact:
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who has verified release of records and power of attorney when applicable
New Orleans Podiatry Associates
2626 Jena Street, New Orleans, LA 70115 - t. 504.897.3627 f. 504.897.3339 3939 Houma Blvd, Bldg. 5, Ste. 217, Metairie, LA 70006 - t. 504.457.2300 f. 504.897.3339nolapodiatry.com | firstname.lastname@example.org
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