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Get MA Signature Healthcare Authorization For Release Of Medical Record Information 2013-2024

Authorization for Release of Medical Record Information Please review and complete the entire form. Your medical records cannot be released until this form is completed, signed by the patient or legal representative and returned to the SMG Correspondence Department. 1. I hereby authorize Signature Medical Group to release information from the medical record of: Patient Name: (First Name) (Middle Initial) Date of Birth:.

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