y name and date of birth (for verification) to [email protected] submitting a message via MyChart, or by providing written notice to: NYU Langone Physician Services, PO Box 415662, Boston, MA 02241 Patient (Parent/Guardian) Signature Date EFTA00313915

ame and date of birth (for verification) to NYUPthiniirenServicestpnyulnic ort submitting a message via MyChart. or by providing written notice to: NYU Langone Physician Services, PO Box 415662, Boston, MA 02241 EFTA00304450 IIBUr HEALTH INFORMATION EXCHANGE. CARE EVERYWHERE AND HEALTHIX CONSENT FORM In this Consent EO

name and date of birth (for verification) to [email protected], submitting a message via MyChart, or by providing written notice to: NYU Langone Physician Services, PO Box 415662, Boston, MA 02241 Patient (Parent/Guardian) Signature Date EFTA00308059 , NYU Langone Health HEALTH INFORMATION EXCHANGE, CAR