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My revoca on will not be e ec ve l delivered in wr g to the person who is in possession of my records. This authoriza n does not include permission to release outpa ent Psychotherapy Notes. alcohol/drug abuse gene. NAME/MRN/DOB AUTHORIZATION TO RELEASE OR OBTAIN CONFIDENTAL HEALTH CARE INFORMATION Print Pa ent s Full Name Date of Birth M/D/Y Street Address Phone Home or Cell City State Zip Code Phone Work Richmond Virginia 23298 Informa on to Be Released To or Obtained From Name Fax Request...
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