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Get The Little Clinic 526A 2012-2022

R RELEASE OF PROTECTED HEALTH INFORMATION Section A: Patient Identification (Required) Patient Name (please include any maiden name or alias): Gender: Date of Birth: SSN # Address: Home Phone: Cell Phone: Work Phone: Email: Home Fax: Work Fax: If requested by Parent or Personal/Legal Representative (Indicate Name & Relationship): Section B: Purpose of Use and Disclosure of Personal Health Information (“PHI”)  Medical Treatment  Insurance / Billing  Legal Purposes  Other .

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