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Directory Results for Authorization to Release Healthcare Ination 6-08 - coastaleyecare to Authorization to Release Healthcare Ination Date: Patient Name: Patient date of birth: Patient Social Security#: I request and authorize DermLogic, PLLC, PA to release healthcare information on the above named patient to: Name: Address:

Authorization to Release Healthcare Ination 6-08 - coastaleyecare
Authorization to release healthcare ination and medical records 14964
Authorization to Release Healthcare Ination Beaverton - healthcenteror
Authorization to Release Healthcare Ination Date: Patient Name: Patient date of birth: Patient Social Security#: I request and authorize DermLogic, PLLC, PA to release healthcare information on the above named patient to: Name: Address: