• Release of Information

  • PATIENT INFORMATION:

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  • REQUESTS RECORDS FROM (WHO HAS YOUR RECORDS NOW):

  • I hereby authorize:

  • TO RELEASE INFORMATION TO (WHO YOU WANT TO RECEIVE YOUR RECORDS):

  • INFORMATION TO BE RELEASED:

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  • Clear
  • If I am unable to personally pick up my records from Peak Gastroenterology Associates PC, I authorize:

  • Should be Empty:
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