• AUTHORIZATION FOR USE OF PROTECTED HEALTH INFORMATION

    COMPLETE ALL SECTIONS, DATE AND SIGN
  • Patient Information

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  • I, *, hereby voluntarily authorize the disclosure of information from my health record.

  • The information to be disclosed from the patient's health record (check all appropriate boxes, AT LEAST ONE OF THE FOLLOWING MUST BE SELECTED):
       
       to:         
    :         
       

  • Clear
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  • Should be Empty: