Colleen Reid

 15/11/10 22:12 PM 
 TO:11167991911 FROM:9425369526 
 Page: 4 
 DocuSign Envelope ID: CD6AFC77-CF28-44AE-AA73-C1B65435D293 
 PATIENT AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION 
 TO: 
 CBTRactics 
 2559 263 Rd, 
 Glen Oaks, NY 11004 
 I hereby authorize the above name facility, any parent company, and any other health plan, physician, health 
 care professional, hospital, clinic, laboratory, pharmacy, medical facility, or any other health care provider 
 that has provided payment, treatment or services to me or on my behalf to release all medical information to: 
 LegalEdge Associates 
 66198 Ernest Forks
Brandonfurt, PW 02955 
 For the use in the pending: 
 DISABILITY INCOME CLAIM 
 This document authorizes the release of all medical information including Immunodeficiency disorders 
 (HIV/AIDS), substance abuse and treatment, mental health/psychiatric treatment, radiology films, pathology 
 materials: 
 Patient name: Colleen Reid 
 ADDRESS: 54115 Michael Station
South Amyhaven, NC 45705
 02/04/19
 BIRTH DATE: 
 Social Security Number: 113267532 
 The treatment dates to be released: (check one) 
 From 15/11/10 to first 
 All records retained by the facility 
 I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke 
 this authorization, I must do so in writing and present my written revocation to: 
 LegalEdge Associates 
 66198 Ernest Forks
Brandonfurt, PW 02955 
 1
