Anthony Walters

 2017 Apr 17 4:9 PM 
 TO:41285008869 FROM:9420313426 
 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: 
 Aegis Law Partners 
 USCGC Hardy
FPO AA 91894 
 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: Anthony Walters 
 ADDRESS: 9843 Walker Well Apt. 204
Lake Matthew, MH 55914
 1987 May 10
 DOB: 
 Social Security Number: 118639232 
 The treatment dates to be released: (check one) 
 From 2017 Apr 17 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: 
 Aegis Law Partners 
 USCGC Hardy
FPO AA 91894 
 1
