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Get Tx St. Luke’s Medical Clinic Authorization Form For Release Of Protected Health Information 2012-2024

Ent Name: DOB: The health information you may release subject to this authorization is as follows: Complete Medical Records Laboratory Tests Prescriptions/Samples Consultation Reports Radiology Reports Speak To Over Phone Progress Notes Physicians Orders ALL OF THE ABOVE If OTHER, please specify: Release my protected health information the following person(s)/entity: Name: Relationship to Patient: Street: City: State: Zip: Phone #: Thi.

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