I or my authorized representative request that health information regarding my care and treatment be released as set forth in this form; in accordance with New York State law and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I authorize the release of the following protected health information:
To send my medical information to:
NEUROTEST OF NEW YORK MEDICAL PLLC
245 5TH AVE 3RD FLOOR, NEW YORK, NY 10016
PHONE: 212-547-0738 FAX: 833-992-2101
I understand that:
**An additional authorization (NYS DOH-2557) is required for disclosures when your medical records contain information relating to Acquired Immunodeficiency Syndrome (AIDS), or Human Immunodeficiency Virus (HIV) including but not limited to test results and the fact that the test was taken.