CONSENT FOR RELEASE OF MEDICAL RECORDS
I hereby give my consent to release any or all requested records as listed below to Hematology and Oncology Associates of Northern California.
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History and Physical
Pathology Reports
Radiology Reports
Laboratory Results
Operative Reports
Discharge Summary/Hospital Reports
Physician Notes
Other:
Patient or Legally Authorized Individual's Signature:
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Date:
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Day
Year
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Date
Patient or Legally Authorized Individual's Printed Name:
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Date:
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Month
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Day
Year
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Date
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