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AUTHORIZATION FOR RELEASE OF CONFIDENTIAL HEALTH INFORMATION I, hereby authorize (Patient Name) Bastian Voice Institute to release to: the following information contained in the patient record of
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Rel 1 of medical can be filled out online or submitted in paper form.
The purpose of rel 1 of medical is to collect and report medical data for analysis and research purposes.
Information such as patient demographics, diagnosis, treatment, and outcomes must be reported on rel 1 of medical.
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