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1215 E. Court Street Seguin, TX 78155 830.401.7237 FAX 830.401.7588 www.grmedcenter.com AUTHORIZATION TO RELEASE/ACCESS PROTECTED HEALTH INFORMATION Patient Name Date of BirthSSNAddressPhone CitySTZipI
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Form Authorization Release Health Info 2020 is a document used to authorize the release of an individual's health information to designated parties.
Individuals seeking to share their health information with third parties are required to file this form.
To fill out the form, provide your personal information, specify the information to be released, identify the recipients, and sign the document.
The purpose of the form is to obtain consent from individuals to share their health information with specific individuals or organizations.
The form requires personal identification details, description of the health information to be released, names of the recipients, and the duration of the authorization.
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