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Record Releaserecord release form pdf

This form is necessary for requesting your medical records to be sent to us or for us to share your medical or behavioral health records with:

  • another medical or behavioral health provider
  • parents or guardians
  • another third party

As our Notice of Privacy Practices fully outlines, we are required by law to obtain your authorization for any use or disclosure of your health information for purposes other than treatment, payment or health care operations.



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Updated: August 21, 2017