Medical Records Release Form
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1MEDICAL RECORDS RELEASE FORM
TO: ________________________
FROM: ______________________
________________________
______________________
________________________
______________________
PATIENT: ___________________________
DATE OF BIRTH: _____________________
I would like to have any and all necessary medical records released to:
___________________________________________________________________
___________________________________________________________________
SIGNATURE _______________________________
DATE _____________
COMMENTS:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
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Parent category: Legal