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Patient Authorization to Disclose, Release and/or Obtain Protected Health Information 1. Patient Information Name Last, First, Former Name(s)/Alias:Street AddressCityMedical Record Number (if known)StateBirthdateZip
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Name- last first mi refers to the format of a person's name, with the last name coming first followed by the first name and middle initial.
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The information reported on name- last first mi typically includes the individual's full name in the specified format.
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