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REQUEST FOR MEDICAL RECORDS Patient's Name: Date of Birth: I hereby authorize Valley Children's Medical Group to request and receive a copy of the specified health information for the individual identified
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Step 1: Start by writing your full name in the designated field of the form.
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Step 3: Indicate the date on which you are filling out the form.
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Step 4: Read and understand the purpose and terms of the authorization document.
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Step 5: Sign the form using your legal signature.
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Step 6: Submit the completed form to the relevant authority or recipient.
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This form is particularly useful for individuals who want to authorize Valley to act on their behalf in specific matters such as financial transactions, legal agreements, or representation in certain situations.
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Both individuals and businesses may need to use this form when granting authorization to Valley.
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