AUTHORIZATION TO RELEASE PROTECTED HEALTH …
Ellicott City Pediatric Associates 9011 Chevrolet Dr., Suite 1-6, Ellicott City, MD 21042 Tel: 410-465-7550 fax: 410-465-6359 Updated 02/2020 AUTHORIZATION TO RELEASE PROTECTED HEALTH INFORMATION (PHI) Mail to Medical Office* Mail to My Address* **mail fee is $8.50 + fee for copying Medical Records** ................
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