Hunter Casey

 2020 July 31 12:48 PM 
 TO:81484854174 FROM:9581382426 
 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: 
 Veritas Attorneys at Law 
 000 Fisher Shoal Suite 809
Gonzalezton, VA 24108 
 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: Hunter Casey 
 ADDRESS: 6368 Dana Drive
Jonathanhaven, NH 39397
 1999 February 08
 date of birth: 
 Social Security Number: 116348332 
 The treatment dates to be released: (check one) 
 From 2020 July 31 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: 
 Veritas Attorneys at Law 
 000 Fisher Shoal Suite 809
Gonzalezton, VA 24108 
 1
