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Health Records Release Authorization the Ohio State  Form

Health Records Release Authorization the Ohio State Form

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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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