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Get Orthopedic Associates Authorization for Release of Medical Record Information

Tate/Zip: «PCity», «PState» «PZipCode» Please Note: A Fee of $25.00 per form (check, visa, mc or money order only) is due at the time of request. Above listed patient authorizes the following healthcare facility to make record disclosure: Orthopedic Associates of Dutchess County, PC Dates and Type of information to disclose: All information needed to process disability claim. ThiS release is valid for a period of one year from the date of signature unless rescinded in writing. The purp.

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