Release of Records Request

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

Date of Request : _____________

TO:_____________________________ (Name of individual or class of entities in possession of the Health Information)

I, _______________________________ (Name of patient or legally authorized representative)

Hereby consent to and authorize you to release to:

Dalip K. Khurana, MD, PLLC.
15 Commerce Drive,
Springville, NY 14141

Copies of:
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

pertaining to the healthcare services that were provided to:

_______________________________________________________________________(Name of patient)

during the following dates of treatment:_______________________________________

This authorization is given for the sole purpose of:
_______________________________________________________________________

and will expire: (expiration date or event)
_______________________________________________________________________

I understand that this authorization is subject to revocation at any time, except to the extent that the individual or entity that is to make the disclosure has already taken action in reliance upon it.
I also understand and agree that this authorization will terminate only upon the execution of my written statement indicating my intent to revoke this authorization and that without such written revocation, this authorization shall remain in full force and effect and shall not otherwise expire.

Date;___________________________ Signature of Recipient: ______________________________

OR Signature of parent or representative: ______________________________

Relationship to Recipient: ______________________________