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L 1idtown Neurology P. C. Husham P. Mishu MD Julian A. Bragg MD PhD Aashish Bharara MD Terri L. Milburn FNP-BC Calli Cook FNP-BC 404-653-0039 Fax 404-653-0159 Alternate Fax 404-688-5622 AUTHORIZATION FOR RELEASE OF INFORMATION RELEASE TO PATIENT NAME SS DATE OF BIRTH PURPOSE/NEED FORDISCLOSURE You are hereby authorized to release copies of Office Notes Lab Reports X-Ray Reports All Records Other This includes the records of the patient s treatment at Midtown Neurology and shall.include any...

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