Add Patient Legal Name
I hereby authorize the following healthcare provider to disclose Protected Health Information of the patient(s) listed above
Cherry Creek Pediatrics 4900 E. Kentucky Ave Denver, CO 80246
Records to be released:
If patient is 18 years of age or older, the form MUST be signed by the patient.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Your information will be encrypted.
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