Adult Neurology
Jan Mashman, M.D.
Diane Wirz, M.D.
Samuel Markind, M.D.
Neil Culligan, M.D.
Anna Alshansky, M.D.
David Greco, M.D.
Robert Bonwetsch, M.D.
Behzad Habibi, M.D.
Michelle Lavallee, M.D.
Loralee Richter, PA-C
Courtney Kennedy, PA-C
Margaret Cavino, PA-C
Melisa Pelikan, RN
Dawn Murphy, RN
Pediatric Neurology
Anna Alshansky, M.D.
Neuropsychology
Erin Lasher, Psy.D.
Jonathan Woodhouse, Psy.D.
Jennifer Prewitt, Psy.D.
Jennifer Denkin, Ph.D
Lori Wagner, Psy.D.
Neurophysiology
Paulette Christie, R EEGT
JoAnn Miles, R EEGT
Physical Therapy
Lisa Dransfield,P.T.,D.P.T.,M.A.
Cynthia Bahr, P.T.
Michelle DiBona, P.T., M.A.
Karen Nell, Licensed PTA
Nicole Saviano, Licensed PTA
Diane Yandow, P.T.
Karen Olencki, MT, MBA
Administration
Arlene Barra
Wendy White
Medical Records Release Authorization
I, ______, authorize and request release of medical records for
Patient Name: ______
Information to be released:
[ ] from [ ] to: ______
______
______
Fax: ______
[ ] from [ ] to: Associated Neurologists, P.C.
69 Sand Pit Road, Suite 300
Danbury, CT 06810
Information requested (please circle):
Office Notes Lab Radiology Billing Other Testing All Records
Date(s) of service(s): ______
Please check below:
____ I understand that my records may contain information regarding the diagnosis or treatment of HIV/AIDS, other sexually transmitted diseases, drug and/or alcohol abuse, mental illness, psychiatric treatment, or neuropsychological testing.
OR
____ I do not give permission to release information regarding the diagnosis or treatment of HIV/AIDS or other sexually transmitted diseases, drug and/or alcohol abuse.
____ I do not give permission to release information regarding the diagnosis or treatment of mental illness, psychiatric treatment, or neuropsychological testing
I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken to comply with it. A copy or facsimile of this Authorization with my signature may be used with the same effectiveness as an original. I acknowledge that there will be a charge of .65 cents per page.
Name: ______Patient DOB: ______
Signature: ______Date: ______