rendered during the following dates: _______________
To: Dr. Valentine Raiteri,
M.D.: 5 W. 19th Street, 9th Floor; New York,
The purpose of this
disclosure is for treatment and continuity of care.
I understand that I
have a right to revoke this authorization at any time. I understand
that if I revoke this authorization, I must do so in writing and
present my written revocation to the treatment facility or clinician
named above. I understand that the revocation will not apply to
information that has already been released in response to this authorization.
I understand that the revocation will not apply to my insurance
company when the law provides my insurance with the right to contest
a claim under my policy.
I understand that this
authorization for disclosure is voluntary and that I need not sign
this form to ensure healthcare treatment.
will expire on ______________________ (if no date is entered it
will expire in 12 months from the date signed).
Signature of patient,
or of parent/legal guardian if patient is a minor:
Print Name: ________________________ Date __________
Signature of Witness
____________________________ Print Name: ________________________