Authorization for Release of Medical Information
Child 1
Patient's name
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First Name
Last Name
Date of birth
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Month
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Day
Year
Date
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Child 2
Patient's name
First Name
Last Name
Date of birth
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Child 3
Patient's name
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Last Name
Date of birth
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Child 4
Patient's name
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I hereby authorize the release of child/ren's medical information to: My 1st Clinic, Dr. Reut Ron Pagi
Address: 8500 Wilshire Blvd Ste 917, Beverly Hills, CA 90211. Phone: (310)789-2058 Fax: (310)602-6498
From:
Name of Doctor/Clinic/Hospital:
*
Doctor's Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Doctor/Clinic/Hospital Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Fax number
Please enter a valid phone number.
Format: (000) 000-0000.
Purpose of disclosure: Treatment/continuity of care
Please release the following:
*
All health information (including psychiatry and psychology notes)
Labs, radiology, pathology and other diagnostic test results
Other
I understand that I may revoke this authorization in writing at any time. Otherwise, this authorization shall remain valid until such time as it is revoked in writing.
Name of parent/guardian:
*
First Name
Last Name
Relationship to patient:
*
Signature
*
Date
*
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Month
-
Day
Year
Date
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