Directory Results for AUTHORIZATION TO RELEASE HEALTHCARE INATION Patients Name: Date of Birth: Previous Name: Social Security: I request and authorize to release protected healthcare information of the patient named above to: This request and authorization to AUTHORIZATION TO RELEASE HEALTHCARE INATION Patients Name: Date of Birth: SSN: Previous Name: I request and authorize to release healthcare information of the patient name above to: Name: Address: City, State: Zip Code: Institutional