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R page for the first 30 pages, plus .84 per page thereafter. Patient Name Date of Birth Contact Numbers ( ) ( / / ) I authorize the following organization to release information as stated below from the patient health information record: INFORMATION TO BE RELEASED FROM: INFORMATION TO BE RELEASED TO: Organization / Person Organization / Person Allegro Pediatrics or Street Address Allegro Pediatrics or City, State, Zip Phone Fax# Street Address City, State, Zi.
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