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                                                 AUTHORIZATION TO TRANSFER MEDICAL RECORDS


          PATIENT INFORMATION: 
                                                       NAME:___________________________________________
                                                ADDRESS:___________________________________________
                                                                  ___________________________________________
                                                                  ___________________________________________
                                                     PHONE:___________________________________________
                                       DATE OF BIRTH:_____________________

          AUTHORIZATION FOR RELEASE:
                            I HEREBY AUTHORIZE: CUSTODIAN OF THE MEDICAL RECORDS OF 
                                                                              LESLIE FARRINGTON,MD
                                                                     SOUTH NASSAU MEDICAL GROUP,PC
                                                 ADDRESS: __________________________________________ 
                                                                     __________________________________________
                                                                     __________________________________________

                             to release, disclose, and deliver all medical information below to:
                                                                     __________________________________________
                                                                     __________________________________________
                                                                     __________________________________________
                                                                     __________________________________________
                                                                     __________________________________________
                                                                     phone_________________ fax__________________


         SPECIFIC AUTHORIZATION:
         I specifically authorize the release of ALL medical information in my record including, but not limited to the 
         following categories protected by state or federal law: 1) Substance abuse (drug or alcohol) treatment; 
         2) Mental health treatment; and 3) HIV-AIDS related information, if such is contained in the records. This 
         authorization includes reports, correspondence, test results, and any other information in the records, 
          whether generated by the authorized provider or another entity.

         I do not give permission for any other use or re-disclosure of this information.

                                                          ________________________________________________________
                                                               PATIENT'S SIGNATURE                                               DATED

         RE-DISCLOSURE: This release does not authorize re-disclosure of medical information beyond the limits of 
         this consent. The recipient of this information is prohibited from using the information for other than the stated 
         purpose, and from disclosing it to any other party without further authorization.