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810031.BLD
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1997-07-22
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#100
@001 Enter the name of the PATIENT:
~Enter the name of the patient requesting release.
~If possible, use the exact name under which the patient
~was treated.
@002 Enter the name of the entity to receive disclosure:
~Enter the name of the person, government agency or firm
~who is to receive the disclosure.
@003 Enter the approximate dates of treatment:
~Enter a range of dates when the treatment took place.
~It is much better to err on the side of a broad range
~of dates than a narrow one. It is acceptable to put in
~a year or years.
#101 Are all prior authorizations canceled?
~In some cases, you might want to revoke any other
~authorizations.
#102
#end control section
#100
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
TO WHOM IT MAY CONCERN
You are authorized to release to: @002, any and all medical
records related to treatment which I may had on the following
approximate dates:
@003
A photocopy of this authorization shall have the same force and
effect as an original.
#101
All prior authorizations are canceled.
#102
__________________________________
@001
Social Security Number: __________________
Date of birth: ___________________________