• Medical Record Release Form

  • Bama Pediatrics and Allergy 2701 20th Ave, Northport, AL 35476 | Phone: (205) 333-5900

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  •  I authorize      to use or release/disclose my health information as described below. Please identify the information to be released:

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  • Please initial each item below to indicate your understanding:

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  • If I fail to specify an expiration date or event, this authorization will expire in twelve (12) months from the date on which it was signed.

    By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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  • Should be Empty: