Release of Records View the Notice of Privacy Practices HereRelease of RecordsIf by mail, send to: Dr. Louis M. Giordano 864 Hooper Road Endwell, NY 13760 607-748-4151 (phone) 607-484-0061 (fax)This record release is for:Requesting records from (Office):*Name:* First Last Date of Birth* Date Format: MM slash DD slash YYYY Name: First Last Date of Birth Date Format: MM slash DD slash YYYY Name: First Last Date of Birth Date Format: MM slash DD slash YYYY Name: First Last Date of Birth Date Format: MM slash DD slash YYYY Electronic Signature (E-Signature) AgreementBy selecting the "I Accept" button, you are signing this Release of Records electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Release of Records. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E-Signature. You also represent that you are authorized to sign this Release of Records for all persons listed on this form.*I AcceptElectronic Signature:Name* First Last Today's Date* Date Format: MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
