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Get Request Medical Records - Integrity Rehab

AR PLEASE CHECK ALL THAT APPLY: Medical Records (email) Billing Records (email) MONTH / YEAR **If sending to a Medical Provider, their email address must be provided** $10 $10 Medical Records (email) Release my information to another person: Attached is copy of Power of Attorney Attached is copy of Medical Consenter RELEASE INFORMATION TO: Payment Method: Check Cash Phone: Individual: Facility: Fax: TOTAL:.

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  • Consenter
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