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Authorization for release of medical information exam p discharge summary written request to the address provided at the top of this form,
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She was discharged from the hospital five days after surgery. the discharge summary was dictated more than two months following the discharge date.
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Patient name: discharge summary laboratory reports emergency medicine reports this authorization will expire 12 months after the date of signing this form.
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Discharge summary emergency room kinds: operative report laboratory tests other from (date) to i need not sign this form in order to
☐ discharge summary. i can refuse to sign this authorization. i need not sign this form in order to ensure
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( ) discharge summary ( ) operative reports ( ) pathology ( ) other microsoft word medical records release form author: administrator created date:
Transport/consultation form should be placed in the maternal transport/ continuity of care after discharge. 2. a written summary will be sent to the provider
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