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LIVERPOOL HEALTHCARE CENTER AUTHORIZATION TO RELEASE AND DISCLOSE PATIENT INFORMATION1. Patient Informational DATE OF BIRTH Address: City: State: Zip: Phone: 2. Release Information From: (Who has
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Want released is a form or document used to request the release of certain information or documents.
Any individual or entity who wants to obtain specific information or documents is required to file a want released form.
To fill out a want released form, the requester must provide their contact information, details of the information or documents being requested, and any other relevant details.
The purpose of want released is to formalize a request for specific information or documents to be released to the requester.
Information such as requester's contact information, details of the requested information or documents, and any additional relevant details must be reported on want released.
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