Release of Medical Records

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Authorization to Release Protected Health Information

This request will be honored within 7-10 business days. There may be a fee depending on the size of your medical records. Prepayment is required before your medical records will be sent.

I authorize Allergy Institute, P.C. to release medical information from my medical record and send it to:

This authorization will automatically expire one year from the date signed. I understand that i may revoke this consent at any time except to the extent that action has been taken in reliance thereon.

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