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Directory Results for AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INATION (*) SECTION REQUIRED FOR COMPLIANCY *Patient Name: *Birth Date: Social Security No: *Provider (Who is releasing information): Address 1: Address 2: City: State: Zip: I hereby to Authorization for Release of Protected Health Ination (Medical Records) Patients Name: Birth Date: Maiden/Former Name: To Release to: Associates of Internal Medicine At Address: 2260 College Avenue Fort Worth, TX 76110 Or Fax:

AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INATION (*) SECTION REQUIRED FOR COMPLIANCY *Patient Name: *Birth Date: Social Security No: *Provider (Who is releasing information): Address 1: Address 2: City: State: Zip: I hereby
Authorization for Release of Protected Health Ination (HIPAA ...
Authorization for Release of Protected Health Ination (Medical Records) Patients Name: Birth Date: Maiden/Former Name: To Release to: Associates of Internal Medicine At Address: 2260 College Avenue Fort Worth, TX 76110 Or Fax: