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AUTHORIZATION TO RELEASE MEDICAL RECORD INFORMATION Patient Name: Date of Birth: I, understand that my medical record contains confidential medical information. If I have discussed certain sensitive

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How to fill out if i have discussed

01

Start by reviewing all the points that were discussed during the conversation.

02

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03

Begin filling out the form by addressing each point that was discussed.

04

Clearly articulate the details and outcomes of each point in the appropriate sections of the form.

05

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