Epstein Secrets

73 (212 )3119-92D0 NIPAA PRIVACY NOTICE • I acknowledge that I hove been given a copy of the Practice's *HIPAA Privacy Notice" which describes the Practice's obligations to ensure the privacy of my health information. The HIPAA Privacy Notice also describes how the Practice may use and disclose my heal

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

Nen York, NV 10073 HIPAA PRIVACY NOTICE • I acknowledge that I have been given a copy of the Practices - HIPAA Privacy Notice" which describes the Practice's obbgations to ensure the privacy of ay health information. The HIPAA Privacy Notice also describes how the Practice may use and disclose my healt

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

acy Notice which describes the Practices Obligations to ensure the privacy of my Stith Inlorrnatban. The HIPAA Privacy Notice also describe* how the Practice may use and disclose my health information for treebnent PaYannt and health care operations. I knew that I have the right to renew the Practices/UR

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