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  • Patient Release Form

    P: (207) 872-0320 F: (207) 872-0330
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  • I hereby authorize Waterville Audiology to release my Medical Records to:

  • I hereby authorize Waterville Audiology to request my Medical Records from:

  • PLEASE FAX RECORDS TO 207-872-0330 

    This consent is effective until terminated by the patient. The fees associated with copies of transferred records is $5.00 for first page and 45¢ for each page after.
  • I Understand That: 


    ■ I can revoke all or part of this authorization at any time by notifying Waterville Audiology in writing. 
    ■ I can refuse to disclose all or some of my treatment records


    ■ Our office routinely makes reminder telephone calls to confirm appointments. If we reach an answering machine, we will leave a message with our practice name and the time and date of your appointment. If you do NOT want us to leave
    you a message, please contact the front desk.


    ■ A refusal or revocation to release some or all information may result in improper diagnosis or treatment, denial of insurance coverage or a claim for health benefits, or other adverse consequences.


    ■ I can have a copy of this form upon request.

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