eck one) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To O Healthcare Provider K Insurance Company or Designee O Attorney K Court K Law Enforcement K Employer Other: Name: Address: Reason for Disclosure K Patient Request K Other: We will

eck One) do include do not include Alcohol and Drug Abuse records. (check one) do include do not include Psychiatric information. (check one) To O Healthcare Provider K Insurance Company or Designee O Attorney O Court K Law Enforcement Other Personal Assistant Name: Lesley Groff Address 9 East 71st Street, NY, NY 10021 O Emplo