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Get Cvs Pharmacy Records Request Form

________________________________________________ Address: ________________________________________________________ Date of Birth _________________________ I hereby authorize CVS/pharmacy to disclose my Patient Prescription Record (PPR), reflecting information regarding my pharmacy services as set forth below: 1. My Patient Name: Address: Address: sed to the following person(s): ___ ___ ______________________ 2. I understand that I may revoke this authorization at any time by writing to CVS/p.

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  1. Click on the orange Get Form button to start editing and enhancing.
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