• Patient Authorization

    Release Medical Records
  • 7405 Shallowford Road, Ste 420

    Chattanooga, TN 37421

    Phone: 423-855-8522

    Fax: 423-855-8533

     

    A copy of this authorization may be utilized with the same effectiveness as an original.

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  • Expiration or revocation of authorization: I understand that I may revoke this authorization at any time and that, unless an earlier date is specified, it will automatically expire 12 months after the date below.

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