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Get Medical Record Release Form

Medical Records Release Form Authorization for Emerald City Naturopathic Clinic, Inc., P.S. to Use or Disclose My Health Care Information Patient name: Date of birth: Previous name: SS#: Address:.

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  3. Fill out the blank areas; engaged parties names, places of residence and phone numbers etc.
  4. Change the blanks with smart fillable areas.
  5. Add the particular date and place your e-signature.
  6. Simply click Done after twice-checking everything.
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