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16418 Cardinal Drive Woodbridge, VA 22192 7037307222 www.pcbcva.com Medical Release and Indemnity Agreement Form Student Information: Students Name: Date of Birth: Home Address: Phone Number: City,

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What is medical release and indemnity?

Medical release and indemnity is a legal document that allows a healthcare provider to disclose a patient's medical information to a third party.

Who is required to file medical release and indemnity?

Medical release and indemnity is typically filed by patients or their authorized representatives.

How to fill out medical release and indemnity?

To fill out medical release and indemnity, patients need to provide their personal information, sign the document, and specify who is authorized to receive their medical information.

What is the purpose of medical release and indemnity?

The purpose of medical release and indemnity is to protect healthcare providers from liability when disclosing a patient's medical information to a third party.

What information must be reported on medical release and indemnity?

Medical release and indemnity must include the patient's name, date of birth, contact information, and specify the authorized recipient of their medical information.

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