The Neuro Clinic, P.C.

I request and authorize the release of healthcare information regarding the patient named above to Dr. Katariwala and staff.  Information may include: Chart notes, X-ray reports, Ultrasound reports, Lab reports, Mammograpy reports, Procedure reports  This authorization stays in good standing until revoked by patient.

Patient's Name

Release Authorization Yes No

I authorize the release of any records regarding drug, alcohol, or mental health treatment to the staff listed previously. Yes No

I authorize the release of my healthcare records for diagnosis and treatment purposes: Yes No

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