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Patient Information
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Patient Name
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Date of Birth
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Address
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Phone Number
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Provider / Facility Releasing Information
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Facility or Provider
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Facility Address
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Phone Number
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Fax Number
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Records Requested
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Date range requested
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Type of information requested (check all that apply)
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Notes and test resulted related to
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Other:
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Reason for disclosure
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Chose all that apply
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Other
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SPECIALLY PROTECTED INFORMATION (choose all that apply) Certain specially protected records may be subject to additional federal or state restrictions on redisclosure.
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I am authorizing release of Specially Protected Information as indicated (Please sign)
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Authorization and Expiration
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This authorization expires six (6) months from the date signed unless another expiration date or event is specified below: Specific expiration date/event:
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By checking below, I am agreeing that:
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Signature of Patient / Legally Authorized Representative
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Printed Name of Legally Authorized Representative (if applicable)
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Date
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If patient is a minor and signature is required: Minor Signature
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Relationship to Patient (if applicable)
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