A
·
B
·
C
·
D
·
E
·
F
·
G
·
H
·
I
·
J
·
K
·
L
·
M
·
N
·
O
·
P
·
Q
·
R
·
S
·
T
·
U
·
V
·
W
·
X
·
Y
·
Z
·
OTHER
·

Directory Results for Authorization for Release of Ination Patient Name Date of Birth Blue Ridge Dermatology Associates, P to AUTHORIZATION FOR RELEASE OF INATION Patient Name Phone Number Address Date of Birth City Social Security Number (last 4 digits only) State, Zip Code I authorize: (Specify where you are requesting information from, i - comhs

Authorization for Release of Ination Patient Name Date of Birth Blue Ridge Dermatology Associates, P
Authorization for Release of Ination PATIENT NAME DATE OF BIRTH PATIENT ADDRESS I, , do hereby authorize the release and/or disclosure of my medical records and diagnostic tests results to Personalized Primary Care in compliance with
AUTHORIZATION FOR RELEASE OF INATION Patient Name Phone Number Address Date of Birth City Social Security Number (last 4 digits only) State, Zip Code I authorize: (Specify where you are requesting information from, i - comhs