** PLEASE NOTE: This authorization will expire 90 days after the date identified above. In the event that you need to cancel this authorization, the cancelation must be received in writing. If the records have already been sent to the organization listed on this request, a separate written revocation must be sent to those persons.
NOTE: When this form is completed, please mail or fax it to your previous doctor in order to have the records copied and sent to our office. THANKS!
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