To Seema Kazi, MD dba Rise Well Behavioral,
I hereby authorize the release of my complete medical records to Seema Kazi, MD dba Rise Well Behavioral for the
purposes of treatment, consultation, and care coordination.
This authorization includes, but is not limited to: hospital discharge summaries, echocardiograms, cardiac
catheterization reports, laboratory results, electrocardiograms (EKGs), physician notes, mental health progress
notes, and any other information relevant to my medical or psychiatric condition.
I understand that I may revoke this authorization at any time by submitting written notice to the Seema Kazi, MD dba
Rise Well Behavioral. Unless revoked in writing, this authorization shall remain in effect indefinitely.
Please list all facility names, hospital names, and/or providers from whom records should be requested:
