Get Authorization to Release Medical Records
Urity Number _______________________ I, the undersigned, authorize the release of, or request access to the information specified below from the medical record(s) of the above name patient. PATIENT INFORMATION IS NEEDED FOR: Continuing Medical Care Insurance Legal Purposes Military Personal Use School Social Security/Disability Other: _______________ _____________________ INFORMATION TO BE RELEASED OR ACCESSED: History & Physical Operative Reports Lab/Path Reports Consultation Report Disch.
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