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Directory Results for Authorization for Release of Medical Records Patient Name Date of Birth Social Security Number Patient Address I, or my authorized representative, request that health to AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Name: ID #: Birth date: Telephone: Address: Release From: (Name of Facility of Clinician Releasing Ination): I authorize release of my medical records from: Facility/Name of

Authorization for Release of Medical Records Patient Name Date of Birth Social Security Number Patient Address I, or my authorized representative, request that health
Authorization for Release of Medical Records Patient Name:
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Name: Date of Birth: / / Phone Email: (mm/dd/yyyy) Legal Guardian name: Relationship to Patient: I request a copy or summary of the following medical records: Complete Medical Record*
AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Name: ID #: Birth date: Telephone: Address: Release From: (Name of Facility of Clinician Releasing Ination): I authorize release of my medical records from: Facility/Name of