Directory Results for Authorization to Release Health Ination Patient Information: Name of Patient Date of Birth Address City, State, Zip Phone At my request, may release the following information: (Name of the entity) Entire record Financial records Office to AUTHORIZATION TO RELEASE HEALTH INATION PATIENT NAME DATE OF BIRTH (FIRST) (MIDDLE INITIAL) (LAST) The purpose of this release form is to authorize RetinaVitreous Surgeons of Central NY, PC to make disclosures of Protected Health