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Medical Records Release Form - East Valley Cardiology

Medical Records Release Form - East Valley Cardiology

Specializing in diseases of the cardiovascular system request for release of medical records i authorize the release of the following medical record photocopies and/or x-ray film copies, to or from the facility/facilities referenced below (to...

Pat.Info.release 7/13/13 Medical Records Release Form

Pat.Info.release 7/13/13 Medical Records Release Form

1625 north alston street foley, alabama 36535 251-970-1959 phone 251-970-1960 fax .gastropc.com medical records release form patient name dob: address: telephone: i hereby authorize the medical records department at gastroenterologists, p.c. to...

Medical Records Authorization Release Form - Atlantic Radiologic ...

Medical Records Authorization Release Form - Atlantic Radiologic ...

345 sea view avenue staten island, ny 10305 phone: (718) 980-4 fax: (718) 980-4873 atlantic radiologic imaging authorization to obtain medical records to further insure compliance with the health insurance portability and accountability act of...

SOUTH SOUND WOMENS CENTER

SOUTH SOUND WOMENS CENTER

South sound women center richard senegal, md laurel dickson, md km walker, md julia richards, md debra johnson, md kendra hansen, pac request for the release of medical records patient name: birth date: former name’s): ssn #: obtain records from:...

ILLINOIS ISSUES AD PLACEMENT FORM - illinoisissues uis

ILLINOIS ISSUES AD PLACEMENT FORM - illinoisissues uis

Illinois issues ad placement form advertiser: ad: issue(s): jan 11 feb 11 march 11 april 11 may 11 june 11 july/aug 11 nov 11 color: 1/3 page (4.83 4.75) full-page (7.33 × 9.5) black and white four-color 1/2 page (7.33 4.75) one color...

Medical records release bformb - Montgomery Cardiovascular bb

Medical records release bformb - Montgomery Cardiovascular bb

Montgomery cardiovascular associates, p.c. h forrest fleming, md david n george, md paul b moore, md wynne crawford, md r eric drum, md beverly a stoudemirehowlett, md darryl a hamilton, md jose l escobar, md tamed ar shad, md liliana arellano, md...

1005 Mar Walt Dr

1005 Mar Walt Dr

1005 mar walt dr. fort walton beach, fl 32547 telephone #: fax #: patient id # internal use only: routine: stat: medical records release form i authorize white-wilson medical center to release or obtain confidential health information about me by...

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