Randy Wright

 
 Northwell 
 Health 
 Authorization for Release of Health Information 
 6. Date or event on which this Authorization will expire (this field must be completed with a data or event): 
 EXPIRE 19/09/24 
 7. PallonVAgenV$urrogate/Guardlan (Signature): 
 8. Date: 
 2 
 Laun 
 16/02/09 
 9. Printed name of person signing this form: 
 10. Authority to sign on behalf of pallent or relationship to patient 
 (if applicable): 
 @ Lisa Arvarado 
 Date/Time 
 Print: Interpreter's Name and Relationship to Patient 
 Signature: Interpreter 
 K. N 
 16/02/09 
 Karla Holemann 
 Print Witness Name 
 Witness to Signature 
 Copy 1 - Patient Medical Record 
 Copy 2 - Patient or Patient's Personal Representative 
 Page 2 of 2 
 VD001 (5/11/19)
