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RELEASE OF INFORMATION AUTHORIZATION FORM Authorization to Release Health Information Patient Information:Name: Maiden Name/Alias: Date of Birth: Social Sec #: Phone: MR#:Health Information Released

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What is name maiden namealias?

Name maiden namealias refers to the original name of an individual before marriage.

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Individuals who have changed their name due to marriage are required to file their maiden name alias.

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The purpose of name maiden namealias is to provide a record of an individual's original name before marriage for legal and identification purposes.

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