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GEORGIA HIPAA COMPLIANT AUTHORIZATION FOR THE RELEASE OF PATIENT INFORMATION PURSUANT TO 45 CFR 164.508
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Patient Name and DOB
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Request
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Records to be released:
• • •
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Text 2
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Coastal Pain Relief Specialists
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Fax: 912-380-6174
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Phone: 912-355-3170
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355 Commercial Dr., Suite C5, Savannah, GA 31406
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Text 3
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Signature of Patient or Guardian:
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Relationship to patient:
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Witness:
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Today's Date:
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