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Get and Sign REQUEST for RECORDSPHI from PREVIOUS PROVIDER  Form

Get and Sign REQUEST for RECORDSPHI from PREVIOUS PROVIDER Form

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PLEASE RELEASE TO Dr Diagnostic Clinic - Largo 1301 2nd Avenue SW Largo FL 33770 Please mail records if more than 10 pages. I acknowledge that I have the right to revoke this authorization in writing to the extent that a covered entity has not already relied upon the patients consent to disclose the PHI. Print Form REQUEST FOR RECORDS/PHI FROM PREVIOUS PROVIDER TO PATIENT PLEASE SEND SIGNED/COMPLETED FORM TO YOUR PREVIOUS PHYSICIAN PLEASE PRINT Patient s Name DC MRN Address Date of Birth...
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