AUTHORIZATION FOR RELEASE OF ALL MEDICAL RECORDS

AUTHORIZATION FOR RELEASE OF ALL MEDICAL RECORDS
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I hereby request that all of my Medical Records with respect to any illness including mental illness, drug or alcohol abuse, and HIV – AIDS testing or treatment be released to:

IDL MEDICAL PA

8767 BOYNTON BEACH BLVD

BOYNTON BEACH, FL 33472

PHONE (561)734-5484 FAX (561)734-5485
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