Medical Record Release Form
If you would like to authorize Brooklyn Acupuncture Project release your records, please fill out the form below.
Your full name: *
Your answer
Your full address *
Your answer
The full name and mailing address of the person or organization to whom Brooklyn Acupuncture Project has your authorization to release records to: *
Your answer
The email address to which Brooklyn Acupuncture Project has your authorization to send your records to:
Your answer
What records do you authorize Brooklyn Acupuncture Project to release? Check the boxes for all types of information you authorize the release of: *
In accordance with New York State Law and HIPAA medical records will exclude any information about 1.) alcohol/drug treatment, 2.) mental health information and 3.) HIV related information unless explicit permission is granted by the patient. Please indicate all records you authorize Brooklyn Acupuncture Project to release by checking the corresponding boxes below.
Required
Expiration of authorization
Revoking authorization
Limitation on record protection
Authorization is voluntary
Patient Signature
Submit
Never submit passwords through Google Forms.
This form was created inside of Brooklyn Acupuncture Project.