Authorization Forms Library
To expedite the process, please make sure you:
1) PRINT the full name of the person seeking care
2) SIGN and DATE the form
3) FAX or MAIL the form to: 866-920-5565 or eHealth Technologies, 250 Thruway Park Drive, West Henrietta, NY 14586
Authorization Forms links:
- opens in a new windowColumbia University Medical Center: Authorization to Release Medical Informationopens PDF file
- opens in a new windowHinge Health: Authorization to Release Medical Informationopens PDF file
- opens in a new windowMayo Clinic: Authorization to Release Protected Health Informationopens PDF file
- opens in a new windowMindstrong Health: Gabe Aranovich, MD
- opens in a new windowMount Sinai Medical Center: Patient Authorization for Release of Medical Informationopens PDF file
- opens in a new windowNew York City Health and Hospitals Corporation (NYCHHC): HIPAA Authorization to Disclose Health Informationopens PDF file
- opens in a new windowNewYork-Presbyterian Hospital: Authorization Form to Disclose Protected Health Information/Medical Records (English) opens PDF file
- opens in a new windowNYU Langone Medical Center: Authorization for Release of Protected Health Information (PHI)opens PDF file
- opens in a new windowThomas Jefferson University: Consent to Release Medical Information
- opens in a new windowUPMC: Patient Authorizationopens PDF file