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Cayuga Medical Center will not condition treatment payment or eligibility of benefits on completion of an authorization. This authorization will expire on date or event. Office Use Only MR Acct. Authorization for Release of Information ID Checked 9 Yes 9 No If No checked why I hereby authorize Cayuga Medical Center to release copies of my medical records as directed below to please enter complete mailing address DESCRIPTION OF INFORMATION Patient Name Dates of Service Date Needed By...

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Check the document for the ID number field.

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Individuals who are applying for a specific identification process that requires ID check number 9 need to fill it out.

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