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WESTERN WAKE PEDIATRICS, PA AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION (Print patient full name) Birth date (Mo/Day/Yr) (Street address) Social Security Number (City, State, Zip code) Phone

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4. Begin by entering the date in the designated field. Use the correct format and ensure it matches the current date.
5. Provide your personal information such as your name, address, phone number, and email address in the appropriate fields.
6. If applicable, enter any assigned identification numbers, case numbers, or reference numbers in the respective section.
7. Clearly state the purpose of your records request. Be specific and provide as much detail as necessary to ensure your request is understood.
8. Indicate the type of records you are requesting. Specify any relevant categories or subcategories to assist the recipient in locating the correct information.
9. If there is a specific time range or date range for the records you are requesting, clearly state it in the designated section.
10. Review your completed form for any errors or missing information. Make sure all fields are filled out accurately.
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Records request 041316doc is a formal document used to request specific records or information from an organization or government entity.

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Any individual or organization seeking specific records or information from the organization or government entity is required to file records request 041316doc.

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Records request 041316doc can be filled out by providing detailed information about the records or information being requested, the reason for the request, and any relevant contact information.

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The purpose of records request 041316doc is to allow individuals or organizations to access specific records or information held by an organization or government entity.

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Records request 041316doc must include details about the specific records or information being requested, the reason for the request, and any relevant contact information.

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