Authorization to Release Information
Authorization to Release Information Revised 06/2015 Form Number to be issued by Vendor Patient Name Birthdate Medical Record Number Address Phone Number Maiden/Other Names I authorize _______________________ to Release to _________________________________ (name) (name) _______________________ _________________________________ (address) (address) ____________________________ ________________________________________ _ (city,state,zip) (city.)
Authorization to Release Information Revised 06/2015 Form Number to be issued by Vendor Patient Name Birthdate Medical Record Number
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