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Directory Results for AUTHORIZATION TO RELEASE MEDICAL INATION PATIENT INFORMATION: NAME ADDRESS CITY / STATE / ZIP PHONE ( ) DATE OF BIRTH / / I HEREBY AUTHORIZE AND REQUEST : (Where records are currently located) NAME ADDRESS CITY / STATE / ZIP PHONE ( ) ) to Authorization to Release Medical Ination Patient Name: Date of Birth: Account # Social Security Number: Phone Number: Complete Address: Address City State Zip I DO NOT AUTHORIZE ANYONE TO *access to my medical records: Signature Date

AUTHORIZATION TO RELEASE MEDICAL INATION PATIENT INFORMATION: NAME ADDRESS CITY / STATE / ZIP PHONE ( ) DATE OF BIRTH / / I HEREBY AUTHORIZE AND REQUEST : (Where records are currently located) NAME ADDRESS CITY / STATE / ZIP PHONE ( ) )
AUTHORIZATION TO RELEASE MEDICAL INATION Patient Name DOB
Authorization To Release Medical Ination Patient Name: Address: Telephone: Birthdate: Released TO: Lifetime Family Care, PLLC 30229 Schoenherr Road, Suite 300 Released FROM: Phone: 5867511177 Fax: 5867511180 Warren, MI 48088 Specific -
Authorization to Release Medical Ination Patient Name: Date of Birth: Account # Social Security Number: Phone Number: Complete Address: Address City State Zip I DO NOT AUTHORIZE ANYONE TO *access to my medical records: Signature Date