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Get and Sign Disclosure Protected Form 2018-2022
X-Ray CD
Dates of service: __________________ to ___________________.
MRI Report
Entire Chart - Hospital
MRI CD
Entire Chart - Physicians Office
CT Scan Report
CT Scan CD
Films
X-Ray Paper Copies
Other Please specify:_______________________________________
Clinic
McBride Orthopedic Hospital is hereby authorized to make disclosures to: Patient
Other individual Organization
No purpose is required when disclosure is being made to the patient. Purpose of release: ...
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