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Our Lone Tree Pediatricians at Lone Tree Pediatrics Form

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Ensure timely processing of request please print all information and fill out completely. The medical record processing fee must be collected prior to record transfer from this office. Fees for duplication of Protected Health Information under HIPAA 164. Type of Information to be released Please check one Copy of entire chart Summary of entire chart Growth Chart Problem list Immunizations Health Information related to the following treatment condition and/or date s I understand that the term...
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