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(2) INFORMATION TO BE RELEASED (3) INFORMATION ... …

Lawson 343855 Rev. 2/16/17 PCI-1400 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Please read carefully before signing and dating. All sections must be complete to be HIPAA compliant. (1) Patient Name: _____ Birthdate:_____ (PLEASE PRINT) LAST FIRST Have you ever used another name (maiden, adopted, nickname, etc.)

Lawson 343855 Rev. 2/16/17 PCI-1400 (12) METHOD (CHOOSE ONE): Paper

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