COMPLETE ALL SECTIONS, DATE AND SIGN
I, or my authorized representative, request that health information regarding my care and treatment be RELEASED 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:
7. Name and address of health provider or entity to RECEIVE this information:
4811 BUCKLEY ROAD
LIVERPOOL, NEW YORK 13088
PH: 315-457-9966 FAX: 315-457-9854
The information to be disclosed from my health record: (Check appropriate box/boxes. Only the selected information will be released)
Medical record requests could take up to 2 weeks to be processed.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.