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AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patients Name: ___ Date of Birth: ___ Phone Number: ___ I authorize Whiting Clinic (the Company) to release the following information from my medical record:
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What is your form coordinator?
The form coordinator is the designated person responsible for managing and overseeing the completion and submission of the form.
Who is required to file your form coordinator?
Any organization or individual who is required to submit the form must designate a form coordinator.
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The form coordinator must ensure that all required information is accurately reported and submitted by the deadline.
What is the purpose of your form coordinator?
The form coordinator ensures that the form is completed accurately and submitted in a timely manner.
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The form coordinator must provide contact information, organizational details, and certification of accuracy.
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