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AUTHORIZATION TO RELEASE HEALTH INFORMATION There may be a fee for copies Patient Name Date of Birth// Telephone I hereby authorize Rush Copley Medical Group to RELEASE TO OBTAIN FROM Person/Facility Agency Address City State Zip Specific description of information that may be used/disclosed Office Visit Notes Dates of Treatment Diagnostic Tests labs X-ray EKG Consultation Notes Immunization Records Patient Messages Please provide complete medical record includes all of the above Other The...
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