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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS To OrthoVirginia Patient Name: (complete legal name including Jr., Sr., I, II, III)MAN# Date of Birth: Social Security Number: To Releaser: (Name of physician,
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2012 2018 orthovirginia willis poa parham henrico shrader farmville johnston chippenham releaser mrn iii hp hanover pertaining ii marys revised

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