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) and other state and federal privacy laws. Section 1: Patient Information Patient Name: Address: City: Date of Birth: State: Zip: Phone: Section 2: Information to be Released (a) I authorize the release of the following health information: Specific Prescription(s): __________________________________________________ Medical Expense Summary (List of all prescription expenses) Designated Record Set (Entire medical record maintained by the Pharmacy) (b) For the following dates of service: All d.

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