Transcription of Authorization to Release Information
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Example: bachelor of science
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, state, zip) _____ _____
Authorization to Release Information Revised 06/2015 Form Number to be issued by Vendor Patient Name Birthdate Medical Record Number
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