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Get Parkridge Valley - Medical Records Release Form. Parkridge Valley

Es. 4. If the requester or receiver is not a health plan or health care provider, the released information may no longer be protected by federal privacy regulations and may be re-disclosed. 5. I understand that I may see and obtain a copy the information described on this form, for a reasonable copy fee, if I ask for it. 6. I get a copy of this form after I sign it. I have read the above and authorize the disclosure of the protected health information as stated. Signature of Patient/Patient s.

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