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Get Saddleback Authorization To Use And Disclose Protected Health Information

Isa, #400 Laguna Hills, CA 92653 I, the undersigned, hereby authorize Saddleback Medical Group, Inc. to release and disclose a copy of my Protected Health Information (Medical Records) to the person/organization specified below: Release Medical Records FROM: Disclose Medical Records TO:  Facility  Patient ________________________________________ ________________________________________ Name of Facility Producing Records Name of Facility/ Patient Receiving Records _______________________.

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