This form is a consent to the release of medical history. The patient authorizes the release of his/her medical history to the specified party within the consent release form. The form also provides that all prior authorizations are cancelled.
Consent Form For Release Of Information In Suffolk
State:
Multi-State
County:
Suffolk
Control #:
US-00460
Format:
Word;
Rich Text
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Client Benefit Services. Form, Description, Pages.I) A signed form of consent from your client if you are a legal representative. Single Point of Access (CSPOA) Committee. If applying for access on behalf of someone else, written consent or a power of attorney is required. Suffolk DBT J.L., LCSW. Suffolk DBT J.L., LCSW. Do we need your consent to use information about you? The application form requests the applicant's consent for the release of the information for that reason. Civil. See Civil Court for additional information.