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Directory Results for Request to Release, Copy, or Inspect Protected Health Ination to REQUEST TO RELEASE, COPY, OR INSPECT PROTECTED HEALTH INATION Patient Chart Number Patient Name Date of Request Patient Address Patient Telephone Patient Name For Record Release or Copies: By signing this authorization, I authorize the

Request to Release, Copy, or Inspect Protected Health Ination
REQUEST TO RELEASE, COPY, OR INSPECT PROTECTED HEALTH INATION Patient Chart Number Patient Name Date of Request Patient Address Patient Telephone Patient Name For Record Release or Copies: By signing this authorization, I authorize the