PATIENT REQUEST FOR MEDICAL RECORDS OR OTHER PROTECTED HEALTH INFORMATION (PHI)TO BE RELEASED TO OUR OFFICE.

Please correct the errors described below.
(name of facility/physician to release the information)

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.

This information was faxed to the above facility by:

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