Permission Authorization Waiver


    Provided below is/are the name(s) of person(s) to whom Stephen I. Goldman, D.O., P.C.,
    (including office staff) has the authorization to discuss any of my medical records.

    Persons to Release Information to:

    I have read all the information above and agree to the statements made. I agree to notify the office immediately, in writing, when changes are to be made to the above listed information.