Physician Information
Physician’s Name: *
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Physician’s Fax: *
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Patient Information
Patient’s Name *
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Patient’s Date of Birth *
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ex: mm/dd/yyyy
New York State law requires all patients requesting the release of their medical records to give permission in writing. Permission to release HIV related records to any person, company, or institution must also be specifically requested in writing.
Records Release *
______ I authorize the release of my complete medical records to Spring Ob/Gyn, PC. My complete medical record includes all progress notes and HIV test results.
Spring Ob/Gyn, PC
135 Spring Street, 2nd Floor
New York, NY 10012
Fax: 212-219-1538
Patient Signature *
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Date of Signature *
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