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Directory Results for Authorization for Release of Patient Health Ination I herby authorize to disclose my individually identifiable health information as described below, which may include information concerning communicable disease such as Human to AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INATION Please Print Clearly Patients Name: M# First Home Address: Middle (if any) Date of Birth: Last Telephone: The undersigned hereby requests and authorizes the release of records from the

Authorization for Release of Patient Health Ination I herby authorize to disclose my individually identifiable health information as described below, which may include information concerning communicable disease such as Human
AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INATION Patient Name DOB: Address City, State, Zip Phone: Please list your PREVIOUS family doctor, OB/GYNE, Pediatrician, Therapist, etc
Authorization for Release of Patient Health Ination PHI
AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INATION Please Print Clearly Patients Name: M# First Home Address: Middle (if any) Date of Birth: Last Telephone: The undersigned hereby requests and authorizes the release of records from the