Medical Record Release

Please correct the errors described below.

Ideal Gynecology

Medical Records Released From:

Medical Records to be Sent to:

Ideal Gynecology
3200 Downwood Circle, NW
Suite 220
Alanta, GA 30327
470-312-3696 Fax: 404-549-3922

Information to be Disclosed:

Revocation

I understand that this authorization will be in effect for one year, unless cancelled by me in writing.

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