Narendra Kansal, MD - Publicforms

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APPOINTMENT REQUEST BACK OR LEG DISABILITY FORM HIPPA NOTICE/ CONSENT FORM MEDICATION REFILL REQUEST NECK DISABILITY FORM NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM NO FAULT CLAIMANT HISTORY FORM NO FAULT INFORMATION SHEET PATIENT INFORMATION PART 2 PATIENT INFORMATION SHEET 1 RECORDS RELEASE FORM REVIEW OF SYSTEMS Welcome to our Neurosurgery practice. WORKERS COMPENSATION INFORMATION SHEET

RECORDS RELEASE FORM

DATE *

PATIENTS NAME *

DATE OF BIRTH *

I HEREBY AUTHORIZE YOU TO RELEASE ANY INFORMATION/RECORDS TO MYSELF THROUGH THE PATIENT PORTAL *

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