New Jersey Medical Records Release Form 3
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PREMIER
UROLOGY
ASSOCIATES,
LLC-­‐LAWRENCEVILLE

GARY
S.
KARLIN,
MD,
FACS

RUSSELL
M.
FREID,
MD,
FACS

JARAD
S.
FINGERMAN,
DO,
FACOS

MICHAEL
S.
COHEN,
MD

Medical Records Release Form
Date________________
(This authorization will not expire)

Patient Name__________________________________

Date of Birth _________________

(Print)

To:
_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

_______________________________________

I hereby authorize the release of my medical records including diagnosis, treatment and/or examinations
rendered to me by your office or institution for any and all conditions.
In agreeing to release my medical records, I am aware that anything pertaining to Psychiatric
Disorders, AIDS/HIV, Drug and/or Alcohol abuse and the treatment of any of