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  • Medical Records Release
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  • Date Format: DD dash MM dash YYYY
  • Date Format: DD dash MM dash YYYY
  • To release to: Multi-Specialty Healthcare

  • I give permission for this medical information to be used for the following reason:

  • Please list any restrictions to the use of the medical record:

  • I understand that I have the right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present the written revocation to the manager of the treatment facility. I understand that revocation does not apply to information that has already been released. I understand that the information received may be subject to re-disclosure and may no longer be protected by federal or state privacy laws. I understand that treatment will not be denied solely for not signing this release.

  • This authorization is good for one year from the date above, unless otherwise revoked.

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