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Get and Sign Release of Information Citrus Orthopaedic & Joint Institute
TO THE RECIPENT BEFORE THE DATE. Signature of Patient or Legal Representative DATE Relationship to Patient if legal representative To recipient of information This information is disclosed to you from records whose confidentially is protected by Federal Law. O. B SS I AUTHORIZE CITRUS ORTHOPAEDIC JOINT INSTITUTE TO RELEASE INFORMATION TO NAME ADDRESS PHONE FAX REASON FOR DISCLOSURE I UNDERSTAND THAT THIS AUTHORIZATION RELEASES MY GENERAL MEDICAL INFORMATION AS WELL AS INFORMATION CONCERNING MY...Show details
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