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Release of Information Request to LaTouche Pediatrics (pdf)

Release of Information Request to LaTouche Pediatrics (pdf) 2025

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The document is a Release of Information form used to authorize the transfer of a patient's medical records from one healthcare provider to LaTouche Pediatrics, LLC. It includes sections for patient and guardian information, details on the specific information requested (such as entire chart or specific reports), the purpose of the release, and consent for disclosing sensitive information. The form requires signatures and is subject to revocation.

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