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E “n/a” if patient is the requestor) I hereby authorize the provider or group named below: Patient Date of Birth Relationship to Patient (note “n/a” if patient is the requestor) Provider/ Group Name Address, City State, Zip: Phone: Fax: to disclose protected health information from the medical record of the above-listed patient, as noted here (check only ONE appropriate box): Entire Medical Record this includes specific permission to release ALL RECORDS and other information regardi.

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