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Directory Results for AUTHORIZATION FOR DISCLOSURE OF HEALTH INATION Patient: Name of Patient Date of Birth Phone Number Street Address City State Zip I authorize the following party: Name of the Health Care Provider/Office Phone Number Fax Number Street to AUTHORIZATION FOR DISCLOSURE OF HEALTH INATION PATIENT: Name of Patient/Previous Names Birth Date/Medical Record Number Street Address City, State, Zip Code AUTHORIZES: RELEASE OF PROTECTED HEALTH INFORMATION TO: Name of Health Care

AUTHORIZATION FOR DISCLOSURE OF HEALTH INATION Patient: Name of Patient Date of Birth Phone Number Street Address City State Zip I authorize the following party: Name of the Health Care Provider/Office Phone Number Fax Number Street
AUTHORIZATION FOR DISCLOSURE OF HEALTH INATION Patient: Name of Patient/Previous Names Birth Date Street Address City, State, Zip Code Authorizes: Release of Protected Health Information To: Name of Health Care Provider/Plan/Other Name
AUTHORIZATION FOR DISCLOSURE OF HEALTH INATION PATIENT: Name of Patient/Previous Names Birth Date/Medical Record Number Street Address City, State, Zip Code AUTHORIZES: RELEASE OF PROTECTED HEALTH INFORMATION TO: Name of Health Care