By signing the form below, I authorize the release of my medical records to Peninsula Doctor.
I hereby authorize (name of your current medical practice)
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To release copies of my medical records to be sent to:
Peninsula DoctorAttn: Dr. Kroes & Dr. Hiroshima401 Burgess Dr. Suite D, Menlo Park, CA 94025Phone 650.800.3365Fax 650.252.0043 (Do not fax more than 15 pages)
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