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AUTHORIZATION FOR RELEASE OF INFORMATIONPatient information: (PRINT name of patient)DOSS×Information to be released from: Name of designated Facility or Provider Address City, State, iPhone Number
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What is (PRINT name of patient)DOBSS# Form?

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Print name of patientdobss is the name of the patient's healthcare provider or physician responsible for completing the medical form.
The healthcare provider or physician attending to the patient is required to file print name of patientdobss.
The healthcare provider or physician can fill out print name of patientdobss by entering their name clearly in the designated field on the medical form.
The purpose of print name of patientdobss is to identify the responsible healthcare provider or physician who completed the medical form for the patient.
The only information required to be reported on print name of patientdobss is the name of the healthcare provider or physician.
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