Womens health alliance, pa pka centre ob/gyn 4414 lake boone trail, suite 205 raleigh, nc 27607 9197884 phone * 9197884464 fax authorization to release healthcare information patients name: chart#: patients address: date of birth: facility /...
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Lauren spillmann, md ann potter, fnpbc julie dubuisson, pac laura santos, atc david wilkenfeld, atc authorization to release healthcare information patients name: date of birth: i request and authorize: office name office address office fax number...
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19075 nw tanasbourne dr, ste 200 hillsboro, or 97124 phone: 5036848252 fax: 8668598195 authorization to release healthcare information patients name: date of birth: previous name: social security #: i request and authorize release healthcare...
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Authorization to release healthcare information patient 's name: previous name(s): date of birth: social security #: i request and authorize: to release healthcare information of the patient named above to: name: address: city: state: zip code:...
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Authorization to release healthcare information patients name: date of birth: social security #: phone #: i request and authorize (doctor/provider/clinic name & address to release healthcare information of the patient named above to: advanced...
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Authorization to release healthcare information patients name: patients date of birth: parent/guardians name: parent/guardians address: i (parent/guardian) request and authorize release healthcare information of the patient named above to: name:...
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Authorization for release of healthcare information and records instructions: fill out this form to allow us to share the member s personal information with the person or entity you name. make sure you tell us: 1) whom you want to receive the...
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Attention: asia martin 4601 charlotte park drive ste. 390, charlotte, nc 28217 phone: 704.529.6161 fax: 704.831.6097 or email completed form to: asia.martin healthstatinc.com authorization to release healthcare information clinic provider?s name:...
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Authorization to use and disclose protected health information this form is available in alternative formats including braille, large print, computer disk, and oral presentation. si usted necesita servicios de intrprete, por favor llame al telfono...
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Adam a. sauceda, ma, lpc, ncc 12030 bandera rd. ste. 108 j helotes, tx 78023 ph. (210) 8530503 fx. 13075350 .synchronicitycounseling.com authorization to release healthcare information client 's name: date of birth: previous name: social security...
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University of virginia health system patient financial services department p o box 800750 charlottesville, virginia 22908 telephone: (434)982-4330 005auth authorization to release confidential healthcare information do not release information if...
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Medstar health at chevy chase 5454 wisconsin ave, suite 401 chevy chase, md 20815 phone: (877) 677-3627 fax: (301) 215-4499 authorization to release healthcare information patient?s name: date of birth: previous name: social security #: i request...
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Static barcode 321 2-hole 1/4 2 3/4 - 3-hole 1/4 4 1/4 authorization to release medical information (not for psychotherapy notes) patient name social security # date of birth maiden/other name patient address street city state zip phone number i...
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Cardiovascular specialists of central maryland authorization to release medical information a community specialty practice of johns hopkins medicine 10710 charter drive, suite 400 columbia md 21044 medical records: (443) 276?6070, fax (443)...
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Authorization to release medical information and/or medical records patient name: date of birth (please print) i authorize (?the clinic?) to use or disclose protected health information (?phi?) contained in my medical records in the following...
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