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Health Records Release Authorization the Ohio State Form
RELEASE OF HEALTH INFORMATION Please print. Incomplete forms will not be processed. See reverse side for instructions and fees. 4. Dates to be Released This can be a very specific date or more general. For example July 15 2012 or June 2012 - Feb 2013. If I selected email as the method of release I understand that email is not a secure form of communication as email communication can be intercepted in transmission or misdirected. I understand that the choice to have my protected health...
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