![297121573-authorization-to-release-protected-health-information-client-name-date-of-birth-last-first-mi-mmddyyyy-i-hereby-authorize-and-request-kingwood-pines-hospital-him-department-to-provide-medical-records-to-receive-from-facility](https://cdn.cocodoc.com/cocodoc-form/png/297121573--Authorization-to-Release-Protected-Health-Information-Client-Name-Date-of-Birth-Last-First-MI-MMDDYYYY-I-hereby-authorize-and-request-Kingwood-Pines-Hospital-HIM-Department-to-provide-medical-records-to-receive-from-Facility--x-01.png)
Authorization to Release Protected Health Information Client Name: Date of Birth: (Last, First MI) (MM/DD/YYYY) I hereby authorize and request Kingwood Pines Hospital, HIM Department, to provide medical records to/ receive from: Facility:
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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