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:

• Columbia University Medical Center: Authorization to Release Medical Information
• Hinge Health: Authorization to Release Medical Information
• Mayo Clinic: Authorization to Release Protected Health Information
• Mindstrong Health: Gabe Aranovich, MD
• Mount Sinai Medical Center: Patient Authorization for Release of Medical Information
• New York City Health and Hospitals Corporation (NYCHHC): HIPAA Authorization to Disclose Health Information
• NewYork-Presbyterian Hospital: Authorization Form to Disclose Protected Health Information/Medical Records (English)
  
• NYU Langone Medical Center: Authorization for Release of Protected Health Information (PHI)
• Oschner Medical Center: Authorization for Release of Confidential Information (English) and Authorization for Release of Confidential Information (Spanish)
• Thomas Jefferson University: Consent to Release Medical Information
• UPMC: Patient Authorization
• Westchester Medical Center: Authorization to Use or Disclose Protected Health Information