PATIENT INFORMATION RELEASE AUTHORIZATION …

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PATIENT INFORMATION RELEASE AUTHORIZATION Fill in the appropriate INFORMATION in each applicable section. Sign and date the form. Incomplete forms will be returned to you unprocessed. A separate AUTHORIZATION must be completed for each request. INSTRUCTIONS PATIENT Full Name: ________________________________________ ________________________________________ ____________ Last First Initial Date of Birth: _________________ Last 4 Digits of SS# _______ Sex: M / F Telephone: (_____) ___________________ Address: Street.

Frequently Asked Questions – Medical Records . Incomplete forms will be returned to you unprocessed. A separate authorization must be completed for each request.

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