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Get FL Gainsville OBGYN Request for Release of Medical Records

1 REQUEST FOR RELEASE OF MEDICAL RECORDS PATIENT INFORMATION: RELEASE RECORDS FROM: NAME:___________________________ OFFICE:______________________ ADDRESS:_________________________ ADDRESS:_____________________ PHONE:__________________________ PHONE:______________________ BIRTHDATE:_______________________ FAX:_________________________ SSN:_____________________________ RELEASE RECORDS TO: Gainesville OB/GYN 6400 W. Newberry Road, Medical Arts Building, Suite 207, Gainesville, FL 3260.

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