RELEASE OF MEDICAL INFORMATION

ALL RECORDS REQUESTS WILL TAKE APPROXIMATELY 5 BUSINESS DAYS
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I hereby authorize the above entity to release information from my medical record to:
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For the purpose of:
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SPECIFIC INFORMATION TO BE RELEASED:
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AUTHORIZATION SIGNATURES


AUTHORIZATION SIGNATURES

NOTE: IF PATIENT IS A MINOR THE PARENT/GUARDIAN MUST SIGN (Excluding exceptions permitted by PA & Federal Law)
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If patient is unable to sign authorization form because of physical condition or age, complete the following:


If patient is unable to sign authorization form because of physical condition or age, complete the following:

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