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Get Primacare Authorization to Release Medical Records

F __________________ zip code _________________________ Phone number _____________________hereby authorizes: PRIMACARE MEDICAL CENTERS To disclose the following specific medical information to: by: mail or fax Name: ______________________________________________________________________________________________ (SELF, PHYSICIAN, HOSPITAL, CLINIC, LAB, RADIOLOGY CENTER OR OTHER HEALTHCARE PROVIDER) Address: ______________________________________________________________________________________.

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  8. Click Done in the top right corne to save and send or download the template. There are several choices for getting the doc. As an instant download, an attachment in an email or through the mail as a hard copy.

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