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PLEASE PRINT AND COMPLETE THIS FORM FOR EACH PHYSICIAN AND
FACILITY SUCH AS A HOSPITAL OR CLINIC. THEN MAIL OR FAX THE
FORM TO THAT PHYSICIAN OR FACILITY SO THAT WE MAY OBTAIN
YOUR CHILD’S MEDICAL RECORDS IN A TIMELY FASHION.
DATE:
__________________
TO:
_________________________________________(doctor,
hospital, clinic)
ADDRESS:
______________________________________________
CITY: __________________________ STATE: ______
ZIP: ______
PATIENT:
______________________________________________
Date
of Birth:
___________________________
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I, the undersigned, do hereby
authorize the release of all medical records belonging to
the above patient, especially those relating to the
patient’s past and present ear, nose, throat, hearing,
speech-language, respiratory, and general head and neck
problems, illnesses, and treatment thereof. Copies of
records should be transferred either by mail, courier,
and/or electronic facsimile to Howard G. Smith, M.D. at the
above address. I understand that I am requesting the
transfer of protected health information about my child and
other family members.
SIGNED:
_________________________________________
Relation to
patient:
_________________________________
DATE:
_______________________
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