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SIGNATURE DATE YOU MAY SUBMIT THIS COMPLETED FORM BY Rev. 03/17 Fax 817 257 7279 Mail TCU Box 297400 Fort Worth TX 76129 E Mail healthinfo tcu. Authorization to Release Healthcare Information Texas Christian University Health Center Medical Director Jane Torgerson MD Amy De la Rosa PA C Leigh Bassler Dixon MD Evelyn Tobias Merrill MD Kerri Waldron MD Johnnie Ireland WHNP Beth Wieser DO REASON FOR DISCLOSURE NAME OF PATIENT OR INDIVIDUAL Choose only one option below...
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