Pay My bill
Home
Locations
Urgent Care
Primary Care
Specialty Care
Services We Provide
Urgent Care
Primary Care
Specialty Care
House Calls
Insurance
Partners
Service Areas
Contact House Calls
Virtual Care
Care Coordination Services
Health Home
Health Home Referral
Specialty Referral
Nursing Home
Employer Health
NY reach
Hospitalist
Atlas IPA
Provider Referral
Patient Resources
Request Patient Medical Records
Payor Request for Medical Records
Hipaa Authorization Online Form
Virtual Visit Instructions
Patients with Special Needs
Accepted Health Plans
Health Plan Customer Service
About
About Essen
Mission
History
Awards
Leadership
Events
News Room
Contact Us
Careers
Training & Careers
International Medical Graduates
AUTHORIZATION FOR RELEASE OF
HEALTH INFORMATION PURSUANT TO HIPAA
Confirm your contact details & Submit
Patient's Name
(Required)
Date of Birth
(Required)
Phone
(Required)
Email
(Required)
Confirm & Submit