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Get GA NGPG Medical Records Request

Birth Requestor Name Relationship to Patient (note “n/a” if patient is the requestor) (note “n/a” if patient is the requestor) I hereby authorize the provider or group named below: Provider/Group Name: _______________________________________ Phone: __________________________ Address: _______________________________________________ __ Fax:_____________________________ to disclose protected health information from the medical record of the above-listed patient, as noted here: (_____.

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