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Release of Medical Information Form
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Patient First Name
Patient Last Name
Date of Birth
Previous Name
Social Security #
Phone
Email
I request and authorize
to release healthcare information of the patient named above to:
Name
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
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Texas
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State
ZIP Code
Fax
This request and authorization applies to:
Healthcare information relating to the following treatment, condition, or dates:
All healthcare information
Other:
*THIS AUTHORIZATION EXPIRES NINETY DAYS AFTER IT IS SIGNED.*
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