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Get Callen Lorde Hipaa Release Form

/ / Section 2: Release Information To I hereby authorize Callen-Lorde Community Health Center to share my individually identifiable health information, which may include protected or privileged information form to the below listed person/organization. Organization and Department: Name: Address: City: State: Zip Code: Phone number: ( ) Fax number: ( ) Section 3: Information to be Disclosed Please check how the information should be initially released: Fax Mail Pick-up Medical Records: P.

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