Fertility consultants andrology/embryology laboratory center for health & healing 3303 sw bond avenue, 10th floor portland, or 97239-4501 patient name: (first) (middle) (last) street address: city: sex: female male state: zip code: employer: work &
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Michael cotter, md, david stewart, md, ashley walsh, md cyndi vista, arnp cnm, ronnie jo stringer, cnm 6400 w. newberry road, suite 207, gainesville, fl 32605 phone: 352.371.2011 fax: 352.384.3611 request for release of medical records patient...
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Attachment a doctors medical center access request form patients name: last first middle home address: home phone: date of birth: date of request: i hereby request that doctors medical center provide me with please check all boxes that apply...
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Medical record fax: 810-220-5519 authorization for release of patient-identifiable health information i, , dob: hereby authorize brighton center for recovery, its director, designee or health information department to: * initials required: 1....
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Medical records request form authorization for disclosure of protected health information to scca patient name date of birth / / address city state zip code phone number i hereby authorize the use and disclosure of my medical records specified...
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5hole 1/4 1 3/8 ctoc authorization for access, use and/or disclosure of protected health information patient name: medical record#: patient address: street apt # city state phone # zip code date of birth / / todays date / / 1. i hereby request...
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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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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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Silver hospital silver cross hospital para authorizaci?n para utilizar y divulgar informaci?n m?dica patient label authorization authorization for use & disclosure health information of health information yo por medio del presente autorizo a...
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