CROSSPARK MEDICAL, PLLC
200 West , 86th Street Suite 1i
New York, NY 10024

CONSENT FOR RELEASE OF MEDICAL RECORDS

FROM: Patient’s Name___________________________________________________________________________________________
Patient’s Address _______________________________________________________________________________________________
Patient’s date of Birth   ___________________________________________________________________________________________
Patient’s Social Security Number ____________________________________________________________________________________

TO: __________________________________________________________________________________________________________
       __________________________________________________________________________________________________________
       __________________________________________________________________________________________________________

I do hereby consent and authorize you to release copies of my medical records, including current and previous medical records form other practices and practitioners, hospitals and / or clinics, which are a part of my medical records. Please send copies of all requested information as soon as possible to the address listed below.