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5400 Broad River Road. Enter the mailing address. 7.Patient Information: I give permission to release the health information of:. I authorize BlueCross to disclose ONLY this PHI: This authorization is made at my request or for this purpose(s):. By completing this form, you are authorizing the South Carolina Department of. I,. , give consent for the release of my personal information to. Print name of Driver the person shown above. This questionnaire and any attachments become the property of the City of Charleston, South Carolina. Physician not to release records without express written consent. CHECK INFORMATION TO BE RELEASED OR REQUESTED: Check all appropriate lines. 1.