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- NC Michael D. Altheimer Authorization For Release Of Medical Records 2015
Get NC Michael D. Altheimer Authorization For Release Of Medical Records 2015-2024
And return this form to request transfer of your medical records. This form must be completely filled out to be considered valid. Please print or type. Patient Name: Date of Birth: Street Address: City/State/Zip: Daytime Phone: ( ) - I Authorize: Name of Doctor: Specialty: Phone: (.
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