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Dr. Nancy Shosid
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About
Dr. Nancy Shosid
Our Office
Resources & Articles
Contact
Process & Services
Evaluation & Consultation
Services
Functional Psychiatry
What is Functional Psychiatry?
Functional Psychiatry Evaluation
Women's Brain Health
Women's Brain Health Evaluation
Evaluation Process
Documents & Forms
Child Evaluation Paperwork
Adolescent Evaluation Paperwork
Adult Psychiatry Paperwork
Functional Psychiatry Paperwork
Women's Brain Health Paperwork
Release of Information Consent Form
Consent for Medical Records
Consent for Medical Records
AUTHORIZATION FOR THE RELEASE OF INFORMATION
I hereby authorize
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To release from the medical records concerning
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To Nancy S. Shosid, M.D. I understand that such disclosure will be made for the purposes of evaluation and/or continued treatment and will be limited to the following specific types of information:
*
History
Physical Examination
Discharge Summary
Psychological Testing
Social History
Laboratory Tests
Other
If other, please describe.
The consent is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon and in any event, shall expire six (6) months from the date of this electronic signature.
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Date
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Thank you!
