Physician s plan weight management raymond a. powell, m.d. 614 4th street 211 n. mt shasta blvd yreka, ca 96097 mt shasta, ca 96067 (530) 842-3088 (530) 926-2502 2410 larkspur ln. 206 washington street redding, ca 96002 red bluff, ca 96080 (530)...
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Medical records release form 3603 davis drive suite c-201 morrisville, nc 27560 phone: 919-234-1582 fax: 919-234-1586 info buildingblockspediatricsnc.com .buildingblockspediatricsnc.com medical record number: (to be filled in by practice) patient...
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Lake ray hubbard pediatrics, pa request for release of medical records: physician name: address: city: state: zip: i hereby request that the medical records for: patients name: dob: patients name: dob: patients name: dob: patients name: dob: be...
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Medical records release form stat request ( ) date: to: fax#: patient name: patient address: dob: ss#: please release ( ) all medical records ( ) radiology reports ( ) labs ( ) all doctor consultation notes on file to dr. at the following address:...
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Authorization for release of medical informationto transfer records from longmont clinic to another medical providersection a . comp lete for a ll au thorizationsi hereby authorize longmont clinic to use or disclose my individually identifiable...
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Authorization to use or disclose protected health information scottsdale healthcare medical group (shmg) 1. patient identifying information: patient name: date of birth: address: city: state: zip code: phone number: date(s) of service(s): a....
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Patient fax transmission date: attention: medical records from: fax to ima 678-474-9752 pages (including cover): important - the documents accompanying this transmission contain confidential information, belonging to the sender, that is legally...
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Kerlan jobe orthopaedic clinic authorization for use or disclosure of health information the completion of this document authorizes the disclosure and/or use of individually identifiable health information as set forth below consistent with...
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Louisville pediatric specialists, psc 6801 dixie hwy., ste. 127 louisville, ky 40258 phone: (502)9355633 fax: (502)9355706 request for medical records (please print) to whom it may concern: i, , the undersigned and legal guardian of the named...
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Primary care physicians of atlanta, p.c. internal medicine 5670 peachtree dunwoody road, n.e. suite 1200 atlanta, georgia 30342 (404) 255-9100 fax (404) 257-7171 .pcpatl.com lonnie herzog, m.d., f.a.c.p. david a. smith, m.d samuel f. adams, m.d....
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14711 ne 29th place, suite #255 bellevue, wa 98007 fax: (425) 4603374 authorization to release patient health information the fee for providing a copy of your medical record release is $1.12 per page for the first 30 pages, plus .84 per page...
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Johnston pain management, p.a. 250 huff drive jacksonville, nc 28546 p: 910.353.4414 f: 910.353.2972 medical records release form patient name date of birth social security number telephone number reason for records request dates of service...
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Dr victoria muir's practice patient access to medical records - request form access to health records under the data protection act 1998 (subject access request) patient s authority consent form for release of health records (manual or...
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Ochsner medical center - baton rouge 17 medical center drive baton rouge, la 70816 phone: (225) 755-4801 fax: (225) 755-4918 authorization for release of confidential information patient's name date of birth address i, hereby authorize full name...
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East alabama medical center medical records patient authorization disclosure for protected health information photo id must accompany request. i. patient name social security # dob patient address city state zip phone ii. i hereby authorize east...
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