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Requesting Information From:
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Patient Information:
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Action:
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Release Information To: Reno Family Medical Group
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Information to be released:
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Dates of Service
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The purpose or need for disclosure: Continued Care
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Review options as check appropriate boxes.
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Authorization: Permission is hearby granted to the above indicated facility to release medical information to
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Reno Family Medical Group. Note: The submission of this form authortizes future disclosures to the same entity within one year
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Patient/Authorized Signature:
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Patient/ Authorized Signature:
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