Printable Medical Records Release Form
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Business Negocio Health Salud authorization autorización Information Información Records Archivos Forms Formulario Date Fecha Medical Records Release Form Formulario de divulgación de registros médicos
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MEDICAL RECORDS RELEASE FORM 1) PATIENT INFORMATION: Name Address City State Zip Date of Birth () Daytime Phone Previous Name 2) AUTHORIZES: Providence Women’s Healthcare Name of Medical Office 1300 Upper Hembree Road, Building 100, Suite D Roswell GA 30076 (770) 670-6170 (770) 670-6171 Address City State Zip Phone Number Fax Number 3a) TO DISCLOSE TO: □ Self, Delivery Options: □Pick up □ Mail to address above □To be picked up: I hereby authorize to pick up my records..
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