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Get Certification Of Medical Records Template

AUTHORIZATION TO DISCLOSE MEDICAL INFORMATION (WTCHP) Patient Name: Health Record Number: Date of Birth: SS# 1. I authorize the use or disclosure of the above named individuals health information.

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  3. Fill out the empty fields; engaged parties names, places of residence and numbers etc.
  4. Customize the blanks with exclusive fillable fields.
  5. Add the day/time and place your e-signature.
  6. Simply click Done after double-examining everything.
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