Records Release Authorization

To: ______________________________________________________________________

(Doctor or Hospital)

______________________________________________________________________

(Address)

I hereby authorize and request you to release to:

CBS Midwifery Inc.

103 Fifth Ave., 3^rd Flr

NY, NY 10003

Office: 212-366-4699 Fax: 212-229-1020

the complete records, diagnoses, treatment, operative reports, laboratory reports, and follow-up, if indicated, pertaining to my care from __________________ to _____________________

Name:_____________________________________________ Date:__________________

Address:__________________________________________________________________

Signature:________________________________________Witness_______________________

(If relative, state relationship)

Records/Chart number, if known:___________________________________________________