Epstein Secrets

rmation to Individualffamily Members In accordance with Federal government privacy rules implemented through the Healthcare Portability Act of 1996 (HIPAA), in order for your physician or staff of the Practice to discuss your condition with members of your family or other individuals that you designate

ng, but if I do, my revocation will not influence any actions the Practice has already taken in reliance on this consent Authorization to Obtain or Release Medical Records from Medical Providerq I hereby authorize East Side Medical Radiology PILO to obtain any and all medical records specifically related to my current

ation to Individualfamily Members in accordance with federal government privacy rules anptitmer tad through the Healthcare Portability Act of 1906 (HIPAA). in order for your physician or staff of the Practice to discuss your condition with members of your family or other individuals that you des-gnatb

ng, but if I do, my revocation wifi not influence any ections the Practice has eroady taken in reliance on this consent. RSORINUatI911 Jo Obtain or Release Medical Records from Medical Providers I hereby authorize East Side Medical Radiology PLLC to obtain any and all medical records spagreenfly rotated to my current

ion to Individualtram_gv Members In accordance with Federal government privacy rules I mpierrien led through the Healthcare Portability Act of 1996 (HIPAA), in order fee your physician or staff of the Practice to discuss your condition with members of your I amuy or other individuals that you despnate,

riting, but d I do, my revocation win not influence any actions the Practice hat ready taker in reliance on this consent Au SI aption to Obtain or Release Medical Records from Medical Provident I hereby authorize East Side Medical Radiology PL LC to obtain any and ail medical records specifically related to my current