10. Authority to sign on behalf of patient: Information to be Disclosed Initials 7. Purpose for Release of Information: Continued Medical Care . 6. Name and Address of Person(s) to Whom this Information Will Be Disclosed: Delmar Family Medicine 1499 New Scotland Rd Slingerlands NY 12159 (p) 518- 320-7517 (f) 518-439-0214 . 5..