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Release of Information / Records Request

Patient Name Date of Birth

Release Records From

Release Records To

Name / Clinic Address

Phone Fax

Records Requested

I authorize the release of the records described above for continuity of care and treatment coordination.

Patient Signature

Signature

Date

Signature is only held in this browser view. Closing or refreshing the page clears it unless printed/saved.

All Shared

Search for

Near

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