I hereby request and authorize all my health care providers to release my health record to WeCare Medical Specialty Group.
I hereby also request and authorize my healthcare carrier, my treating physician and doctor, and lab to disclose,
make available and furnish to WeCare Medical Specialty Group all information including: healthcare insurance,
medical records, X-rays, MRI report, IME report and/or copies thereof related to my examination, confinement of
treatment and to permit WeCare Medical Specialty Group to inspect and make copies, or abstracts thereof.
Note: If these records contain any information from previous providers or information about HIV/AIDS status,
cancer diagnosis, drug/alcohol abuse, or sexually transmitted disease, you are hereby authorizing disclosure of this
Please send the records by fax, mail or email to:
2040 Millburn Ave #201, Maplewood, NJ 07040
Phone: 973-996-2990 Fax: 908-242-3911
I understand that after the custodian of records discloses my health information it may no longer be protected by
Federal privacy laws. I further understand this authorization is voluntary and that I may refuse to sign this
authorization. My refusal to sign will not affect my ability to obtain treatment, receive payment, or eligibility for
benefits unless allowed by law. By signing below I represent and warrant that I have authority to sign this document
and authorize the use or disclosure of protected health information and that there are no claims or orders pending or
in effect that would prohibit, limit, or otherwise restrict my ability to authorize the use or disclosure of this protected