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Vincent S Scott, M D , F a C O G Urogynecologist  Form

Vincent S Scott, M D , F a C O G Urogynecologist Form

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My Name print DOB Release my records TO Provider Provider phone number By Fax Fax number By Regular Mail I understand that a fee of 30. Com MEDICAL RECORDS RELEASE FORM By signing below I authorize Scott Gynecology Pelvic Surgery PC to release my complete health record to myself or the medical provider listed below. I attest that the records I am requesting belong to me personally or I am the legal guardian of the person whose Fax to 678-264-0939 OR email to medicalrecords scottgynecology. 00...
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