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Directory Results for Authorization of Release of Healthcare Ination Telephone Number: Fax Number: Patients Name: Date of Birth: Previous Name: Social Security #: I request and authorize release healthcare information of the patient named above to: Name: to AUTHORIZATION OF RELEASE OF IDENTIFYING HEALTH INATION

Authorization of Release of Healthcare Ination Telephone Number: Fax Number: Patients Name: Date of Birth: Previous Name: Social Security #: I request and authorize release healthcare information of the patient named above to: Name:
AUTHORIZATION OF RELEASE OF HUMAN RESOURCES ADMINISTRATION HRA CASE INATION
AUTHORIZATION OF RELEASE OF IDENTIFYING HEALTH INATION