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Get Tidelands Health Authorization for Release of Medical Information

Carolina Phone: 843-520-8404; Fax: 843-520-8073 _____Tidelands Waccamaw Community Hospital 4070 Highway 17 Bypass, 29576-5033 Murrells Inlet, South Carolina Phone: 843-652-1098; Fax: 843-652-1085 To release the following information from the health records for: 1. Patient’s Name:_________________________________ Patient’s Date of Birth:___________________________ Patient’s Social Security Number(Last 4 digits): XXX-XX- __ _ _ Patient’s Telephone:________________ 2. Covering The Pe.

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