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
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: ______________________________