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

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

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