• PATIENT IDENTIFICATION INFORMATION

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  • PATIENT'S AUTHORIZATION :

  • , hereby give permission for the hospital, Clinic or doctor named below to release all records or information, including any alcohol or drug abuse treatment records.

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  • TO: (Print name & address of hospital, clinic, or doctor where care is received)

  • MIDWEST ORAL & MAXILLOFACIAL SURGERY, PA

  • Should be Empty: