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Get CA BASS Medical Group-Neurology Authorization For Release Of Patient Health Information 2017

Kim Dr. Kai C. Lee Erik Kuecher PA 400 Taylor Blvd, Suite 301 Pleasant Hill, CA 94523 (925) 602-7060 FAX: (925) 602-7070 AUTHORIZATION FOR RELEASE OF PATIENT HEALTH INFORMATION This authorization allows the healthcare provider(s) named below to release confidential medical information regarding my medical history, illness or injury, consultations, prescriptions, treatment, diagnosis or prognosis, correspondence and/or medical records those from my other health care providers that the ab.

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