AUTHORIZATION FOR THE RELEASE - …
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION Health Data Services, Ab-7 9500 Euclid Avenue Cleveland, OH 44195 216/444-2640 800/223-2273 ext. 42640 Fax: 216/445-7589 Patient:________________________________ ___________ SS#:____________________________________ ______________ Clinic#:________________________________ ___________ Date of Birth: ______ / ______ / __________ Telephone #:______________________________________ _ Current Address: _______________________________________ City:_____________________ State:______ Zip:_____________ I hereby authorize the Cleveland Clinic to RELEASE the health information indicated below that is contained in my patient records to the Recipient named below.
This consent is subject to revocation at any time except to the extent the action has been taken thereon. This authorization and . consent will expire one year from the date of authorization written below.
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