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Directory Results for Authorization To RELEASE Healthcare Ination Patients Name: DOB: Nicknames or preferred name: I request and authorize Arnette Family Dentistry to RELEASE healthcare information of the patient (name listed above) to the named family to AUTHORIZATION TO RELEASE HEALTHCARE INATION Patients Name: Patients Date of Birth: Parent/Guardians Name: Parent/Guardians Address: I (parent/guardian) request and authorize release healthcare information of the patient named above to:

Authorization To RELEASE Healthcare Ination Patients Name: DOB: Nicknames or preferred name: I request and authorize Arnette Family Dentistry to RELEASE healthcare information of the patient (name listed above) to the named family
Authorization to Release Healthcare Ination Patients Name: DOB: PID: Previous name Social Security # I request and authorize to release protected healthcare information of the patient named above to: Austin Breast Imaging 12319 N
AUTHORIZATION TO RELEASE HEALTHCARE INATION Patients Name: Patients Date of Birth: Parent/Guardians Name: Parent/Guardians Address: I (parent/guardian) request and authorize release healthcare information of the patient named above to: