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Complete Home & Office Legal Guide
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Complete Home and Office Legal Guide (Chestnut) (1993).ISO
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810031.fib
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1993-08-01
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646b
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26 lines
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
TO WHOM IT MAY CONCERN
You are authorized to release to: ________________________, any
and all medical records related to treatment which I may had on
the following approximate dates:
________________________________________________________________
A photocopy of this authorization shall have the same force and
effect as an original.
________________________________________________________________
__________________________________
Social Security Number: __________________
Date of birth: ___________________________