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Get Coastal Spine And Pain Center Authorization For Release Of Protected Health Information 2016-2024

Address 2: City: State: Zip: Phone: Fax Number: I hereby authorize my protected health information from the above provider to be released to: *Recipient's Name (Who is receiving the information): Address 1: Address 2: City: State: Zip: Phone: Fax Number: *This authorization will expire upon the following: (Fill in the Date or Event, but not both.) (If no expiration is specified, this authorization will expire 90 days from the date signed.) *The following information may be disclosed (Choose on.

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