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Get Peachtree Spine Request For Access To And Authorization For Use And Disclosure Of Protected Health

(Last) Phone #: (Maiden/Other Name) Medical Record #: Address: City: St: Zip: Zip: I hereby authorize Peachtree Spine Physicians to Disclose my Protected Health Information to: Name: Attn: Address: City: St: Relationship: Phone: Fax: RECORD DELIVERY METHOD (select one): Secure Electronic Access Mail (via US Postal Service) Pick up at Peachtree Spine Physicians Email: INFORMATION TO BE RELEASED Medical Records Billing Records Diagnostic Films Other: I.

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