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SAMPLE FORM:COPY, PASTE and EDIT.
AUTHORIZATION FOR EXAMINATION
OF
PHYSICIAN’S RECORDS
To ________________________:
I authorize you to furnish a copy of the
medical records of ________________________,
( name of patient of “myself” )
covering the period from _________,
20 ____ to ___________, 20 ____ or to allow those records to be inspected or copied by _____________________. I release you
from all legal responsibility that may arise from this authorization.
Signed _________________
Date __________________
Witness
____________________________
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