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Directory Results for AUTHORIZATION TO DISCLOSE HEALTH INATION I hereby authorize the use or disclosure of information from the medical records of: Patient Name: Date of Birth: Medical Record #: Social Security #: (optional) I authorize the following to Authorization to Disclose Health Ination I, the undersigned, authorize: Foothills Neurology: 4530 East Muirwood Drive Suite 111 4809612365: Phone Phoenix, AZ 85048 480 9612382: Fax Stuart Hetrick, DO Padma Mahant, MD Melinda Preston,

AUTHORIZATION TO DISCLOSE HEALTH INATION I hereby authorize the use or disclosure of information from the medical records of: Patient Name: Date of Birth: Medical Record #: Social Security #: (optional) I authorize the following
Authorization to Disclose Health Ination I, the undersigned, authorize Sonoran Orthopaedic Trauma Surgeons to disclose the information described below to the recipient(s) described below
Authorization to Disclose Health Ination I, the undersigned, authorize: Foothills Neurology: 4530 East Muirwood Drive Suite 111 4809612365: Phone Phoenix, AZ 85048 480 9612382: Fax Stuart Hetrick, DO Padma Mahant, MD Melinda Preston,