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Directory Results for Authorization to Release Protected Health Ination Patients Name: Birth Date: Last 4 digits of S to AUTHORIZATION TO RELEASE PROTECTED HEALTH INATION Printed Patient Name Date of Birth Wake Ear Nose and Throat Specialist are authorized to release protected health information about the above named patient to the entities named below

Authorization to Release Protected Health Ination Patients Name: Birth Date: Last 4 digits of S
Authorization to Release Protected Health Ination Plain Language 10-16-2015
AUTHORIZATION TO RELEASE PROTECTED HEALTH INATION Printed Patient Name Date of Birth Wake Ear Nose and Throat Specialist are authorized to release protected health information about the above named patient to the entities named below