Authorization to Release Medical ... - Adventist Health
to pick up my medical records. ***FOR OFFICE USE ONLY*** ( REQUEST COMPLETED - DATE: _____ PREPARED BY: _____ PAGE COUNT: _____ ( IDENTITY OF INDIVIDUAL AND/OR LEGAL REPRESENTATIVE VERIFIED (STAFF INITIALS): Notes: *112* Authorization to Release Medical Info Adventist Health. AUTHORIZATION TO. RELEASE MEDICAL INFORMATION, ENG. 8707F86-0623 … ................
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