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Innovative Healthcare Solutions. World Trade Center National Responder Health Program Medical Records Release Form Patient Name (Please Print) WTC Number Date of Birth (mm/dd/YYY) I Authorize: Name

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Patient's Date of Birth Age Sex Race Gender Ethnicity Height Weight Head/Neck Gender Surgical Specialities Procedure Other? Surgical Procedure Method of Release? If Other... How Did You Get Here? Place of Birth City State (Do you live in the U.S.) ZIP Code Other? (Select One) - - - - - Emergency Department Other? Other? Inpatient Hospital Self/Family Referral to Health Outreach Workers Inpatient Facility Other? Other? Health Plan Employee Self Referral to Workplace Other? Other? Patient Group Name (Select All) — None Employer or Employee Primary Provider of Health Care Workplace of Record - - - - - Other? Contact Information: Email Phone Number (Optional) E-mail Address (Optional) - - - - - Other? If you need to send a fax number to us, choose 'Yes' in the 'Other' field above. For any other questions, please call us at.

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