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MEDICAL RECORDS 811 West Main Street Suite 204 Lexington SC 29072 Phone 803 359-8855 Fax 803 359-1257 3240 Sunset Boulevard West Columbia SC 29169 LexPediatricPractice. Com A Lexington Medical Center Physician Practice Authorization for Release of Protected Health Information Patient s full name at the time of treatment Date of Birth / / Social Security Number Date s of treatment Purpose of release I authorize the following provider/entity to release my health information to...
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