Dec30 1603 :00p p.

3
Dec. 29. 2016 4.07PM No . 2722 P. 3

NYU LANGONE MEDICAL CENTER

NYU Hospitals Center and NYU School Of Medicine

Purpose for release ofinfonnation (check box bd.9-w; pursuant ~o NYS law,~ ~ppply): . h ( j"\Dr L '.'L../'
O At my request D Continuity of Care er Other (please eicplaic.): CJ} f..J U ) e. U \....--'fU,

Format (check box below):

SPaper .
D Electronic
Descriptioia of information being r eleued (check box below):
O All abstract (summary of relevant infonne.tion) for the following date(s):

@' All records related to the following datc(s) :

From Sul"){] J..61S -/o /JV i..J
D Other(specify): - - - - - - - - - - - - - - - -- ------~~,
Include information relating to (initial beside each applicable category):
,r Alcohol Ol' brug Treatment
~ Mental Health Treatment
'f Genetic Testin Information
'ii Ps ~bothera Notes If yes lease com lete the additione.1 authorization fonn for this
'f HIV-Related infonne.tion (If yes. lease complete an official NYSOOH HIV relea5e form)
Person.riceiving this information~
~Sendto:
Name H{) cm+ e( Address
J,H-Je!lf ,',Vi .' Pt..tf.'d( F 1'/Jl-oC'f) Fax Number(ifacolicablc:): J.J J... _. .36..S - .l.S J... {
O I will pick it Up
D My pctSonal representative (name) _ _ __ _ _ __ _ _ __ _ _ __ _ will pick it up.
(identifit11tum r~qtdredfor pick-11p)

Allthorization will end bJ one (1) year unlesJ the information is completed below:
D Specific event or date (specify): - - - - - - -- - -- -- - -- - - -- - -- -
All items on this form htvc been completed and roy questions have been answered. Jn addition, I have been
provided a copy of this fonn.

Signa --+.u..i.~~-__...~.!4--'-......._::;;;__W,;....:;.~
:;.._
, Date: AM6l
(Patient or person authorized to sign)
lfthe consenting party is other thafl the patient, print name a~d relarionship to patient. Supporting
documentaliotl shoufd be provided ot the time ofrhe request.
Name/R.elacicmship:_ _ _ _ _ _ _ _ _ __ _ _ __ _ _ __ _ _ __ _ _ __ _ _

(tage 2 of2j (Rev. 05i1 4)

Dec301603 :00p p.2
Dec. 29. 2016 4:07 PM No. 272 2 P. 2

NYU LANGONE MEDICAL CENTER

NYU Hospitals Center and NYU School Of Medicine
AUfflORIZATlON FOR RELEASE OF PROTECTED HEALTH INFORMATION (PHl)
U'1der f~i:rol and s1a1e law, we need your written aitlhorlzaMfl befoYe we share your protected health irrformarton
(PHI). Please read tlte information below corefuily before .rigntng this form . A flflel(/s 111,at /Je compl~d.

Patient Name Ph.ant Numbe1

L(; Q.; A 7;? b7lo

1, or my authorized representative, hereby authorize NYU Langone Medical Center to s are my PHI.
I understand that:

1. Information relating ro ALCOHOL/DRUG ABUSE, MENTAL HEAL TH TREATMENT,

GENETIC 'l'ESTING, and/or CONFlDENTlAl. HIV~RELATED INFORMATION will not be
shared wiless l specifically give permission by placing my initials in the appropriate space(s) on page 2.
2. Bx.ccpt for HIV infonnation, information that is shared because of this authorization may be shared again
by the recipient and no longer protected by federal or state law. Unless permitted by federal or state law,
ifr arn giving pe1missioo to share HIV-related ioformation, the recipient cannot share this infonnation
without my pennission. I can ask for a list of people who may receive ar use IllY HIV-relaced information
without authorization. Ifl experience discrimination because of the use or disclosure ofHlV-related
information, I may contact the New York St.ate Division of Human Rights at (212) 480-2493 or the New
York City Commission of I-lwmm Rights at (212) 306-1450. These agencies aro resPonsible for
protecting my rights .
3. I can revoke this authorization at any time by providing a written notice of revocation to the department
at the address listed below for submission of this fonn. This r~ocation will be effective except to the
extent NYU Langone Medical Cc:nter has already relied upon this authorization.
4. Signing this authorization is voluntary. NYU Langone Medical Center may not condition treatment,
payment, enrollment in health plan&, or eligibility for benefits on my signing or refusal to sign this
authorization, except in limited circumstances.

Indicate whicli Provider/Entity from which you are requesting records:

Check :rrovider/EntSC}' Contact Phone Submit the fonn in pmon or mail to the
Bel aw Releasing the Information Number 11ddreu below:
NYU Langone Medical Center
Tisch Hospital, Rusk Institute, 212-263-5490 HIM Department
Ambulatory Ca.re Center
650 First Avenue, 6"' Floor. NY. NY 10016
Hospital for Joint.Diseases
Hospital for Joint Diseases 2l2-598-6790 lDM Department
JO l E I J'h Street, Room 200, NY. NY I 0003
Clinical C&Dcer Institute, HIM DepartmcJ)t,
Clinical Cancer Center 212-73J -5096 160 E 341h Street, Io- Floor,
NY, NY lOOI6

ti Faculty Group Practice Office/

rhysici1111
Indiv idual office Directly to the individual physiciiUl office

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