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Elliott Keller Welcome To The 21st Century Dear Patient A new highly sophisticated computerized instrument now allows us to provide a more thorough medical analysis of your eye. Signature Date General Medical Records Release and Authorization for Use of Disclosure of Protected Health Information Address Phone Last four SSN Phone/Fax To disclose/release the following information check all applicable All records Office notes previous 2 years Laboratory/Pathology records previous 3 years...
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