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Directory Results for Authorization Release of Confidential Health Information I, , hereby authorize Name: Address: TO RELEASE TO: Name: Address: The following information contained in the patient record of: (Patients Name) born , residing at - lfpc to Authorization Release of Information ljc

Authorization Release of Confidential Health Information I, , hereby authorize Name: Address: TO RELEASE TO: Name: Address: The following information contained in the patient record of: (Patients Name) born , residing at - lfpc
AUTHORIZATION Release of Dental Records
Authorization Release of Information ljc