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THIS IS NOT A PRINTABLE FORM. PLEASE FILL ALL THE FIELDS AND HIT SUBMIT AT THE END.

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AUTHORIZATION TO RELEASE INFORMATION

Patient Name (Last):

(First):

DOB:

SS#:

Cell #:

Day Phone #:

INFORMATION REQUESTED FROM:

Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

INFORMATION REQUESTED TO:

Name:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Information I would like sent / requested:

Copies of pertinent info only (H&P, OP reports, Labs, Imaging Reports)

Copy of entire medical record

Other (Please Specify)

Patient Signature:
(Your Name is Your Electronic Signature)

Date:

THIS IS AN ONLINE FORM. DO NOT PRINT