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Authorization for Release of Confidential Records
Requesting XRay Imaging
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* Indicates required question
Legal Name:
*
Your answer
Date of Birth:
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MM
/
DD
/
YYYY
Phone Number
*
Your answer
I hereby authorize the named parties to release any medical information including the diagnosis, medical records and x-rays rendered to me during my treatment.
Electronic Signature:
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Your answer
Office Information:
*
Release Records From:
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