West End Medical Associates

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Release of information - Online Form

AUTHORIZATION TO RELEASE INFORMATION FOR PATIENT
I Voluntarily authorize Dr. (please choose Dr. name)
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from West End Medical Associates to:
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Written and/or verbal information from the record of:
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This information is to be used for the purpose of:
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Specific Information to be released:
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  1. I acknowledge and hereby consent to such, that the released information may contain alcohol, drug abuse, psychiatric, HIV testing, HIV results, or AIDS information. ______ (please type your initials)
  2. I may refuse to sign this authorization and my treatment will not be conditioned upon signature of this authorization (except for non-health related services such as pre-employment testing, life insurance exams, or drug screenings).
  3. I may revoke this authorization at any time in writing, but if I do, it will not have any affect on any actions taken prior to receiving the revocation. Further details may be found in the Notice of Privacy Practices.
  4. If the requestor or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed.
  5. I understand that I may see and obtain a copy of the information described on this form, for a reasonable copy fee, if I ask for it.
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logo bigWest End Medical Associates

Welcome to our outpatient psychiatry practice, West End Medical Associates. We are research-clinician faculty at the Columbia University College of Physicians & Surgeons. All of the physicians specialize in psychiatry, are Board Certified by the American Board of Psychiatry & Neurology, and are licensed to practice medicine in the State of New York.

 

We strive for excellence in systematic evaluation; and in compassionate, professional, discreet, and evidence-based clinical care. If you have a suggestion or comment, please write it down and hand it to the receptionist or mail it to the office, att: Dr. Seidman.

 

Thank you for allowing us to participate in your care.

footer contact information

617 West End Ave, Suite 1B

(side entrance on 90th Street)

New York, NY  10024

 

Phone and SMS: (212) 579-0339

Email: office@westendmed.com

Fax: (212) 202-4187

Office Hours:

Monday - Thursday, 9AM to 10PM

Paypal link:

PayPal.me/westendmed

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