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Get UCSF Medical Center Radiology Release Form

With you to your appointment. To: Name of physician or institution Street address City State Zip Code I am requesting and authorizing you to release and furnish medical records and information to: UCSF Interstitial Lung Disease Program 400 Parnassus Ave., Room 591, Box 0359 San Francisco, CA 94143 tele: (415) 353–8764 | fax: (415) 353–8944 The requested records and information pertain to: Patient/client name Date of Birth This authorization shall become effective immediately and shall.

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