AUTHORIZATION FOR THE RELEASE OF RECORDS TO TOC
AUTHORIZATION FOR THE RELEASE OF MEDICAL INFORMATION AND RECORDS
From the Records Compiled on:
Patient Name
SSN
DOB
Parent or Legal Guardian
do hereby authorize:
1.
Complete Name, Address of Person/Agency with Possession of Records
Date of Treatment of Problem Treated
2.
Complete Name, Address of Person/Agency with Possession of Records
Date of Treatment of Problem Treated
3.
Complete Name, Address of Person/Agency with Possession of Records
Date of Treatment of Problem Treated
4.
Complete Name, Address of Person/Agency with Possession of Records
Date of Treatment of Problem Treated
To release any and all medical records and information concerning me to:
The Orthopaedic Center 927 Franklin Street Huntsville, AL 35801 Phone: (256) 539-2728 Secure Fax: (256) 539-2666
Patient Signature
Date
Witness Signature
Date
................
................
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