AUTHORIZATION FOR RELEASE OF RECORDS "*" indicates required fields I hereby authorize Becker ENT to transfer, release, or obtain information on the following:Please select the provider you are scheduled to see*Select…Dr. Samuel BeckerDr. Michael LupaDr. Robert MignoneDr. Aubrey McCulloughDr. Paul FrakeDr. Kathryn EdwardsMegan Seery, NPDr. Daniel BeckerDr. Kenneth RosensteinDr. Luke KimDr. Naomi GregoryAndrea Farwell, NPDr. Kirkland LozadaDr. Omar AhmedDr. Jamie ZachariasDr. Naba SharifDr. Richard SterlingDr. Gileno Fonseca-FilhoDr. Elias AklDeidre Emerich, NPShannon Erlich, NPCarly Schiff, SLPKrysten Sears, SLPAlyssa Molfese, SLPDiana Becker, SLPRebecca Grossman, SLPDr. Neha SirohiDr. Joanna KamDr. Vir PatelDr. Alisa YamasakiDr. Sara Ghannam(Name of Patient)* (Date of Birth)* MM slash DD slash YYYY (Social Security Number) (Telephone Number)*Email* Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code OBTAIN FROM:(Institution/Physician) (Attention) Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFax SEND OR FAX TO:(Institution/Physician) (Attention) Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code PhoneFax PLEASE CHECK SPECIFIC INFORMATION REQUESTED* ALL RECORDS LABORATORY X-RAY REPORT CT REPORT MRI REPORT PROGRESS NOTES OPERATIVE NOTES AUDIOGRAM ALLERGY TESTING SLEEP STUDY/CPAP OTHER (PLEASE SPECIFY) OTHER (PLEASE SPECIFY)* (SIGNATURE OF PATIENT OR PARENT/LEGAL REPRESENTATIVE)*(RELATIONSHIP TO PATIENT)* (DATE)* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged. Δ