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Medical Records Release Form






Business Network Members
  1. Kodiak Community Health Cent
  2. Jax Auto Mart
  3. Stonehearth Remodeling
  4. Benchmark Door






Medical Records Release Form Template

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Medical Records Release Form


Patients Name: ___________________________________________

I do hereby request and give permission to release my Medical Records for the following time period:

____/____/______ - ____/____/______

From the following Medical Clinic:

Name: ____________________________________________________

Address: _________________________________________________

City: __________________________________________ State: ______ Zip: ____________

Office Phone: __________________________________________

Please Release the above mentioned Medical Records to:

Name: __________________________________________________

Address: _______________________________________________

City: __________________________________________ State: ______ Zip: ________________

Office Phone: ___________________________________________

Please include a copy of ID:

Type of ID presented: ___________________________________

ID #: ___________________________________________________

Printed Patient Name: ___________________________________

Date of Birth: ____/____/______ Social Security #: ___________________

_________________________________________________________
Patient Signature










Business Network Members
  1. Philip Enterprises
  2. Cindy' s Cleaning and Buildi
  3. GA Telesis, LLC
  4. Tanon's Host Home






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