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Dr. Ryan D. Kauffman 1136 JACKLIN ROAD MILPITAS CA 95035 Phone/Fax 408-262-1371 AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION Patient s Name Date of Birth Social Security Case / MIsc Address City State Zip Code Phone Fax To release my healthcare information to Thrive Milpitas to the following address Fax 408-262-1371 This request and authorization applies to Imaging Reports MRI / X-Ray / Other Healthcare information relating to the following treatment condition or dates All healthcare...
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