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Directory Results for Authorization for Release of Protected Health Ination Patient Name: Address: Other Name: Birth date: Soc to Authorization for Release of Protected Health Ination Patient Name: DOB: / / I hereby authorize the Heuser Hearing Services Center to Release To or Release From (Please Check One) Please list below person or entity records are to be - -

Authorization for Release of Protected Health Ination Patient Name: Address: Other Name: Birth date: Soc
Authorization for Release of Protected Health Ination Patient Name: Date of Birth: I request that my protected health information be released to: Name: Phone# Address: Delivery Instructions: (O NE MUST BE SELECTED) Mail directly to
Authorization for Release of Protected Health Ination Patient Name: DOB: / / I hereby authorize the Heuser Hearing Services Center to Release To or Release From (Please Check One) Please list below person or entity records are to be - -