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Medical Release/Request

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PATIENT INFORMATION:
MM slash DD slash YYYY
RECORDS TO BE RELEASED:
Exam Needs:*
MM slash DD slash YYYY
INFORMATION REQUESTED FROM:
PREMIER MOUNTAIN IMAGING CENTER*
RELEASE INFORMATION TO:
PATIENT
Deliver Via:*
PERMISSION:
hereby grant permission for you to release confidential health information about me, by releasing a copy of my medical record or a summary, or narrative of my protected health information to the physician, person, facility, or entity.
Clear Signature
MM slash DD slash YYYY
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