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AUTHORIZATION TO RELEASE MEDICAL INFORMATION (Important: All blanks MUST be filled in)*Patient: Birthdate: *Address: *City: State: Zip: *Telephone: () Released to:Released to:TLC Pediatrics 4520 Linden
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Important all blanks must be properly filled out to ensure accurate information.
All individuals or organizations mandated to do so by the governing body.
Follow the guidelines provided by the governing body and provide accurate information in all sections.
The purpose is to gather necessary information for record-keeping and compliance purposes.
All relevant information as per the requirements set by the governing body.
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