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Office Use Only: EPM ___ Patient Name: ___DOB: ___Phone Number: ___ Email: ___ Address: ___AUTHORIZATION TO RELEASE MEDICAL INFORMATION I authorize and direct Complete Family Medicine, a service of

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5. If there are any supporting documents required, make sure to attach them as per the instructions.
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8. If you have any doubts or questions, don't hesitate to seek clarification or assistance from the relevant authority.
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We require all new refers to a specific filing requirement that must be completed by eligible individuals or entities to report certain information.

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