Authorization for Release of Health Information

I, or my authorized representative, request that health information regarding my care and treatment be released as set forth on this form. I understand that:

1. This authorization may include disclosure of information relating to CONFIDENTIAL HIV/AIDS RELATED INFORMATION only if I select the appropriate checkbox. In the event the health information described below includes any of this type of information, and I have check the box, I specifically authorize release of such information to the recipient indicated.

2. With some exceptions, health information once disclosed may be re-disclosed by the recipient. If I am authorizing the release of HIV/AIDS related information, the recipient is prohibited from re-disclosing such information or using the disclosed information for any other purpose without my authorization unless permitted to do so under federal or state law. If I experience discrimination because of the release or disclosure of HIV/AIDS related information, I may contact the New York State Division of Human Rights at 1-888-392-3644. This agency is responsible for protecting my rights.

3. I have the right to revoke this authorization at any time by writing to the provider. I understand that I may revoke this authorization except to the extent that action has already been taken based on this authorization.

4. Signing this authorization is voluntary. I understand that generally my treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditional upon my authorization of this disclosure. However, I do understand that I may be denied treatment in some circumstances if I do not sign this consent.

Please Note

All medical record release submission requests for Eastside Gynecology, the Manhattan Center for Gynecology and the Manhattan Center for Vaginal Surgery are processed and completed by the Manhattan Center for Womens' Health.

Please allow 5-7 business days for all records requests to be processed. We do not email patient records.
Patient Name Patient Name First Last
Valid Email Address

Confirm Email Address

Please be sure a valid email address is entered. You will receive a copy of this request submission.
Patient Current Address Patient Current Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Patient Date of Birth Patient Date of Birth / MM / DD YYYY
Patient Social Security Number
Mobile Phone Number Mobile Phone Number - ### - ### ####
RECORDS RECIPIENT
Recipient Name
Method of Records Delivery
Recipient Mailing Address Recipient Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Recipient Fax Recipient Fax - ### - ### ####
Recipient Phone Recipient Phone - ### - ### ####
Purpose for Release of Information
Unless previously revoked by me, the specific information below may be disclosed from this date Unless previously revoked by me, the specific information below may be disclosed from this date / MM / DD YYYY
Unless previously revoked by me, the specific information below may be disclosed to this date Unless previously revoked by me, the specific information below may be disclosed to this date / MM / DD YYYY
Include HIV/AIDS related Information

Include HIV/AIDS related Information Yes
If not the patient, name of person signing form If not the patient, name of person signing form First Last
AUTHORIZATION
Authority to sign on behalf of patient
All items on this form have been completed by the aforementioned patient or their duly authorized representative.

All items on this form have been completed by the aforementioned patient or their duly authorized representative. ACKNOWLEDGED
Date of Request Submission Date of Request Submission / MM / DD YYYY
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Spam Protection. Please answer this simple question:
What is the sum of 2 and 3 ?

Authorization for Release of Health Information

Authorization for Release of Health Information

Please Note

RECORDS RECIPIENT

AUTHORIZATION