Tài liệu Authorization to release medical records pptx
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AUTHORIZATION TO RELEASE MEDICAL RECORDS
MEDICAL AUTHORIZATION
TO: [NAME OF DOCTOR]
RE: [NAME OF PATIENT]
You are hereby authorized and directed to furnish to [NAME AND ADDRESS OF RECIPIENT OF
MEDICAL RECORDS] copies of any clinical notes and medical records prepared by you relating
to the above patient.
You are requested not to disclose any other information to any other persons without my written
authority to do so.
Dated: [DATE]
_______________________________
[NAME OF PATIENT]
