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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Extend Fertility Medical Practice 200 West 57th Street, Suite 1101 New York, NY 10019 Patient Name (Print) Date of Birth I authorize the office of

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What is extend medical release form?

The extend medical release form is a document that allows an individual to designate another person to make medical decisions on their behalf if they are unable to do so.

Who is required to file extend medical release form?

Any individual who wants to designate a healthcare proxy or make their medical wishes known in case of incapacitation is required to file an extend medical release form.

How to fill out extend medical release form?

To fill out an extend medical release form, you will need to provide your personal information, the name of your healthcare proxy, and specify the medical decisions they are authorized to make on your behalf.

What is the purpose of extend medical release form?

The purpose of an extend medical release form is to ensure that your medical wishes are known and followed in the event that you are unable to make decisions for yourself.

What information must be reported on extend medical release form?

The extend medical release form must include your personal information, the name and contact information of your healthcare proxy, and specific instructions regarding your medical care and treatment.

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