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Directory Results for Authorization for Release of Protected Health Ination Please fill out the numbered items 1-11 (1)Patient Identification Printed Name: Address: (2) Information to be released by: Mercy Hospital Date of Birth: Last 4 of Social Security No to AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INATION Release to Total Family Care: 12350 Westheimer, Suite G Houston, TX 77077 Phone: 281

Authorization for Release of Protected Health Ination Please fill out the numbered items 1-11 (1)Patient Identification Printed Name: Address: (2) Information to be released by: Mercy Hospital Date of Birth: Last 4 of Social Security No
Authorization for Release of Protected Health Ination PLEASE PRINT CLEARLY AND FILL OUT ALL NUMBERED SECTIONS
Authorization for Release of Protected Health Ination Records
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INATION Release to Total Family Care: 12350 Westheimer, Suite G Houston, TX 77077 Phone: 281