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I UNDERSTAND THAT ACTIVE ORTHOPEDICS DOES NOT RELEASE COPIES OF RECORDS RECEIVED FROM OTHER HEALTH CARE PROVIDERS. PRINT NAME SIGNATURE Date WITNESS Date TAMPA 6101 WEBB RD STE 303 TAMPA FL 33615 PHONE 813 885-5888 FAX 813 885-5888. MEDICAL RECORDS RELEASE AUTHORIZATION Patient Name AddressCity State Zip Phone DOB Which records are needed Reason for transfer/request I the undersigned do hereby authorize and direct you to Furnish records TO Active Orthopedics LLC from Release records FROM...
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