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HEALTHYSTARTPEDIATRICS AUTHORIZATIONFORRELEASEOFMEDICALRECORDS PatientName: DateofBirth: / / Address: Phone No: SSN#: Iherebyauthorize Phone No: Fax No: toreleasethefollowingmedicalinformationforthepurposeof()continuityofcareor
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Oformrpleasebespecific is a form used for reporting specific information.
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