Authorization to release protected health information client name: date of birth: (last, first mi) (mm/dd/y) i hereby authorize and request kingwood pines hospital, him department, to provide medical records to/ receive from: facility: regarding...
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Arkansas department of human services po box 8076 little rock, ar 722038076 recipient name & address will pull from mail file street address city, st zip code dear recipient (pull from mail file) federal law requires the department of human...
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Consent / authorization for release of information 1. i hereby authorize: name: address: city: state: phone: fax: zip: to release the following information from the health record (s) of patient s name: phone number: date of birth: covering the...
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Patient authorization for releaseof health records to external partiesi authorize the disclosure of information from my treatment records to:name of recipientrelationship to the patienti give authorization to disclose the following information:all
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Omb no. 3095-0039 expires 07/31/2014 authorization for release of military medical patient records 1. social security no. or service no. note: records center personnel complete blocks #1,2,3 and 6. this center has received a request from the...
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Joseph m. dement, m.d. christopher l. elder, m.d. s. david jarrett, m.d. t. marcus barnett, m.d. ron heninger, p.a. authorization for use and disclosure of protected health information: to aoa patient name: date of birth: address: city: state:...
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Brookwood internists, p.c. 513 brookwood blvd., ste. 50 birmingham, al 35209 authorization for use and disclosure of protected health information i, , hereby authorize brookwood internists, p.c., its employees and/or agents to use and/or disclose...
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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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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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The rubino ob/gyn group medical release form 101 old short hills road, suite 101, west orange, nj 07052 tel: 9737361100 / fax: 9737361134 request form to send medical records to the rubino ob/gyn group this form is a request to release medical...
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