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5555 Peachtree Dunwoody Rd NE, Suite G65

5555 Peachtree Dunwoody Rd NE, Suite G65-2025

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The document is a Request for Access and Authorization for Use and Disclosure of Protected Health Information from Peachtree Spine Physicians. It allows patients to authorize the release of their medical records, billing records, and other health information to specified individuals or entities. The form includes sections for personal information, delivery method, specific information to be released, purpose of disclosure, and acknowledgment of understanding regarding privacy rights and costs associated with obtaining records.

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