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Authorization Forms LibraryKathy Dutton-Fanning2020-10-27T14:17:07-04:00

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 Information
  • opens in a new windowMayo Clinic: Authorization to Release Protected Health Information
  • opens in a new windowMindstrong Health: Gabe Aranovich, MD
  • opens in a new windowMount Sinai Medical Center: Patient Authorization for Release of Medical Information
  • opens in a new windowNew York City Health and Hospitals Corporation (NYCHHC): HIPAA Authorization to Disclose Health Information
  • opens in a new windowNewYork-Presbyterian Hospital: Authorization Form to Disclose Protected Health Information/Medical Records (English)
  • opens in a new windowNYU Langone Medical Center: Authorization for Release of Protected Health Information (PHI)
  • opens in a new windowThomas Jefferson University: Consent to Release Medical Information
  • opens in a new windowUPMC: Patient Authorization
  • opens in a new windowWestchester Medical Center: Authorization to Use or Disclose Protected Health Information
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