Authorization for Release of Medical Information

Please correct the errors described below.

I hereby authorize and request

to disclose information from my medical records to:

M. Jammal, M.D. Pediatrics

Mary ann Ellis-Jammal, MD

151 N Sunrise Ave, Suite 1403

Roseville, CA 95661

Phone: (916) 771 - 4414

Fax: (916) 771 - 4411

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Thank You! M. Jammal, M.D. Pediatrics

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