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Authorization to Release/Obtain Medical Records

Authorization to Release/Obtain Medical Records Today’s Date: _____/_____/_____ Patient Name: _____ (First) (MI) (Last)

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Patient Interview Form - Arizona Digestive Health

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Patient Interview Form Patient Information Allergies Past or Present Medical Conditions Reminder Preference I would like to receive preventive care and follow up care reminders.

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OCA Official Form No.: 960 AUTHORIZATION FOR RELEASE …

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Instructions for the Use of the HIPAA-compliant Authorization Form to Release Health Information Needed for Litigation This form is the product of a collaborative process between the New York State

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Authorization for Release of Protected Health Information

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521125 – REV 05/19 AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION HIM ROI Authorization – File Only ORIGINAL to Chart PHOTOCOPY as needed for Patient Page 1 of 2 Authorization for Release of Protected Health Information Please note that blank items on this form may cause major delays in processing your request.

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Authorization to Furnish and Release Information (PDF)

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Authorization to Release Veterinary Records - Adobe

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Authorization to Release Veterinary Records PLEASE FAX THE RECORDS REQUESTED BELOW AS SOON AS POSSIBLE TO PETSMART AS NOTED BELOW: Attn: _____ Fax: _____

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Authorization to Release Information - maine.gov

www.maine.gov

DHHS Authorization Form 1/19 Page 2 of 2 What is the purpose of the release? Please check or write a response. To coordinate or manage my care For a legal matter, including to provide testimony A personal request To see if I qualify for benefits or insurance Other _____ Please check and print clearly below: Send my information to Get my information from:

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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

www.lifebridgehealth.org

This authorization will expire within 1 year unless otherwise indicated. The consent to disclose information may be revoked by me at any time in writing except to the extent that action has been taken in reliance thereon, as set forth in the

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AUTHORIZATION TO RELEASE COPIES OF A MEDICAL RECORD

www.med.umich.edu

MICHIGAN MEDICINE Health Information Management (HIM) Release of Information (ROI) Unit 2901 Hubbard Rd #2722 Ann Arbor, Michigan 48109-2435 Phone: (734) 936-5490

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