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Get RiverBend Authorization for Use or Disclosure of Medical Record Information (Formerly 204-RG) 2016-2024

Ase Print): Patient Address: City: State: Medical Record #: Form Reviewed By:__________________ Date of Birth: Phone #: Email: Zip: Name of Insurance Plan: I hereby Authorize Riverbend Medical Group to: Please choose one: Release my medical record information to Obtain medical information from Name/Facility: Attention: Address: Phone #: City: State: Purpose of Request: Personal Zip: Referral Fax #: Legal Insurance Other _________________________ . Transfer from Practice/.

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