Patient Name
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Date of Birth - Month
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Date of Birth - Day
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Date of Birth - Year
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Release of Information:
I authorize the release of information including appointment dates and times, diagnosis, records; examination rendered to me and claims information.
Patient Name
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Please Do Not Release My Information
Do not release information to anyone other than my Primary Care Physician and/or Referring Physician
This release of information will remain in effect until terminated by me in writing.
Signature
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Date - Month
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Date - Day
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Date - Year
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Which office location would you like this form sent to?
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