Patient Forms

Authorization and Release Forms

Medical Records Release:

• Permission for Communicaiton
• Request to Obtain Copy of Records
• Permission of NYSWC to Obtain Records About You
• Permission to Release Records About You

3rd Party / Insurance Authorization Release and Forms:

• Appointment of Representative
• Stryker Mild Verification of Benefits and Authorization
• Release for SPRCARE (SPRINT PNS)
• Authorization to Release Records to New York State DFS for External Appeal
• PATIENT AUTHORIZATION FORM FOR THE INTRACEPT® PROCEDURE