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Mail Thank you,

Arianna Figueroa
REQUESTPractice
FOR ACCESS TO HEALTH
Office INFORMATION BY PATIENT OR
Associate
Chat Health Information PERSONAL REPRESENTATIVE
Management Department
Orlin & Cohen
I or my Personal Representative Medical
hereby Specialist
request that Group
No$hwell Health provide access to my health information as
1099I am
described in this form. Targee
making Street
this request under the provisions of the Health Insurance Po$ability and Accountability
Act “HIPAA”) that entitle me to access my own health information including directing it to another person or entity (45
Meet CFR 164.524). Staten Island, New York 10304
Phone: (718) 448-3210 Ext 244
Patient Name: _____________________________________________ Patient Date of Bi$h: __________________
Fax: 718-448-7979
Patient Address: Patient Telephone #:
The information contained in this electronic e-mail transmission and any attachments are intended only for
the use of the individual or entity to whom
_________________________________________________________ or to which it is addressed, and may contain information that is
____________________________________
privileged, confidential and exempt from disclosure under applicable law. If the reader of this communication
_________________________________________________________
is not the intended recipient, or the employee or agent responsible for delivering this communication to the
1. No$hwell Healthintended
Entity/Facility to Release
recipient, youthis
areInformation (From Who):
hereby notified ________________________________
that any dissemination, distribution, copying or disclosure of this
communication and any attachment is strictly prohibited. If you have received this transmission in error,
2. Person or Entityplease
Who Willnotify
Receivethethis Information
sender (To Who):by telephone and electronic mail, and delete the original
immediately
communication and any attachment from any computer, server or other electronic recording or storage
device
£ To me £ To Another Personor or
medium. Receipt
Entity - Provide by anyone
Name other than the intended recipient is not a waiver of any attorney-
________________________________________________
client, physician-patient or other privilege.
3. Manner Form/Format Delivery Details

£ Paper copy Mailing Address:

£ Secure USB
2 A!achments Flash Driveby Gmail
• Scanned
£ CD
£ Regular Mail
V087 Updated Request-
for-Medical-
Records.pdf
£ Paper copy 677 KB
£ Pick up at facility £ Secure USB Flash Drive N/A
£ CDto
Consent (where available)
Unenc…
£ Secure email Email Address:
£ Unsecure email (By checking here, I acknowledge
£ Electronic mail that e-mail sent unencrypted means others may be able
to access the information and read it once it is
Pleasetransmi'ed over the internet.) Received, thank you.
con!rm receipt. Thank you!
£ Fax N/A Fax Number:

£ Other Please explain:

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VD087
(9/28/21)