Russell Heath DVM

 2019/08/07 15:8 PM 
 TO:30373076211 FROM:9270969826 
 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: 
 JusticeCraft Law Group 
 701 Bryant Lakes Apt. 876
Courtneyville, OH 07582 
 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: Russell Heath DVM 
 ADDRESS: 420 Tracy Freeway Apt. 511
Daniellebury, FM 51140
 1989/16/06
 birth date: 
 Social Security Number: 119835332 
 The treatment dates to be released: (check one) 
 From 2019/08/07 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: 
 JusticeCraft Law Group 
 701 Bryant Lakes Apt. 876
Courtneyville, OH 07582 
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