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I further understand that I have a right to receive a copy of this authorization upon request. Identifying Information Patient s Name at Time of Treatment Please Print Address City State Zip Date of Birth Social Security ---- Date of Treatment or if long term Beginning Dec 31 2017 Information Requested Discharge Summary History and Physical Operative Report X-ray Clinical Laboratory EKG EEG All Records Other Signed Consultation Patient Parent/Legal Guardian Witness signature Revised...
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The purpose of internal use only is to ensure that sensitive information remains confidential and is only accessed by authorized personnel.
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