Main Clinic Office

New Medical Treatment Initiative, PLLC
450 Park Avenue South, Suite 202
New York, New York 10016
Phone: (212) 297-6105
Fax: (877) 797-2712
Email: office@nmti.nyc


Business Office

New Medical Treatment Initiative, PLLC
The Graybar Building
420 Lexington Avenue, Suite 300
New York, New York 10170
Phone: (212) 297-6105
Fax: (877) 797-2712
Email: office@nmti.nyc

Your Name*

Your Email*

Date of Birth*

Phone Number *

Name of your primary care physician

Phone number for primary care physician

Inquiry

Instructions to complete the Medical Record Release Form:
1) Download and print the general purpose medical release form OR the HIV status release authorization form
2) Complete ALL sections marked with the ✖ and then sign and date the form
3) Fax or email the form to your doctor’s office
4) Finally let us know that form was submitted, office@nmti.nyc or 212-297-6105

 


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