Who are you authorizing to receive your Protected Health Information (PHI)?(Please allow 48 hours for this request to be processed)
Description of PHI to be disclosed (enter the dates of the specific information you want to be released)
This authorization will expire at the end of the current calendar year, unless you specify an earlier termination. You must renew or submit a new authorization after the expiration date to continue the authorization.
I authorize Weinstein Imaging Associates to disclose or provide the above protected health information (PHI) about me to the individual/entity identified above.
By submitting the information below, you are electronically signing this form.