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New Jersey Medical Records Release Form 3

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This form is provided by Premier Urology Associates in Lawrenceville, New Jersey to authorize the disclosure or release of one person's protected health information.

New Jersey Medical Records Release Form 3
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Medical Records Release Form
Date________________
(This authorization will not expire)
Patient Name__________________________________ Date of Birth _________________
(Print)
To:
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
I hereby authorize the release of my medical records including diagnosis, treatment and/or examinations
rendered to me by your office or institution for any and all conditions.
In agreeing to release my medical records, I am aware that anything pertaining to Psychiatric
Disorders, AIDS/HIV, Drug and/or Alcohol abuse and the treatment of any of these disorders, if
they are listed in my medical records, will also be released.
________________________________________Date ___________ __________________________
Signature of Patient or Legal Representative Legal Representative Relationship
________________________________________
Witness’s Signature
New Jersey Medical Records Release Form 3