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Directory Results for AUTHORIZATION FOR DISCLOSURE OF MEDICAL INATION Patient Name: MI DOB Street Address: City / State / Zip: Records Released To: Records Released From: Optima Health and Vitality Center 3321 A Golf Rd to AUTHORIZATION FOR DISCLOSURE OF MEDICAL INATION Patients Name: Date of Birth: (Please Print) Address: Telephone No: Street I hereby authorize: City State Zip code Frederick Gastroenterology Associates 310 West Ninth Street Frederick, MD

AUTHORIZATION FOR DISCLOSURE OF MEDICAL INATION Patient Name: MI DOB Street Address: City / State / Zip: Records Released To: Records Released From: Optima Health and Vitality Center 3321 A Golf Rd
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INATION Patients Name Chart # Fee: (Please Print) Address: Telephone No: Street City I hereby authorize: State Zip code Frederick Gastroenterology Associates 310 West Ninth Street Frederick, MD
AUTHORIZATION FOR DISCLOSURE OF MEDICAL INATION Patients Name: Date of Birth: (Please Print) Address: Telephone No: Street I hereby authorize: City State Zip code Frederick Gastroenterology Associates 310 West Ninth Street Frederick, MD