Epstein Secrets

East Slily Medical Rudloff I'I,I.f Sieved D. Wolff M. 171) r. 77". st., 'St". York %% 10073 (212 )

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

:ast Ride Medical ItacSolo*, PI.I.0 Sites cis D. Wolff M.D. Ph.D. 170 E nr• fit_ Nen York, NV 10073 HI

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

East Side II Itau i'1.1.(' ?Hest% 1). Wolff 111.1). l'Ii.1). 170 K n- St., Nen I (irk %I 100 7:$ HIPAA PRIVACY NOTICE • I acknowledge that I have been given • copy el the Pratte:a 'HIPAA Pr

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