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Get Columbia University Authorization to Release Medical Information

http://www.cumc.columbia.edu/hipaa/ Form Revised: August 11, 2008 Authorization to Release Medical Information Patient Name: ________________________________ Date of Birth: __________________ Address: ________________________________ Phone: City: ______________ State: ______ ___________________ Zip: ______ I authorize the release of the following protected health information:  Office Notes /Name of Physician. __________________________________________________  Pathology Report.

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