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Authorization for Release of Protected Health Information Patient s Name Date of Birth Address City State and Zip Code Phone 1 -- Phone 2 -- I hereby authorize Harborside Spine and Sports Center Physician s or Office Name To release my confidential health information as described below to Myself In the following manner Copies by mail Copies to be picked up Copies by fax Other My authorization is for the use and disclosure of the following records Medical Records Date Lab Reports X-Rays...
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