southernentandsinus.com - Release of Medical Records FROM Southern ENT & Sinus Center

RELEASE OF MEDICAL RECORDS AND/OR INFORMATION
I, Name , AUTHORIZE SOUTHERN ENT & SINUS CENTER, PC, TO RELEASE MY RECORDS TO THE FOLLOWING (where records are to be sent)
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Fax #:
PATIENT:
PATIENT’S DATE OF BIRTH:
Signature of Patient or Responsible Party

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RELEASE OF MEDICAL RECORDS AND/OR INFORMATION