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Medical Records Release Form Signature: Date: - David L Reeve

Medical Records Release Form Signature: Date: - David L Reeve 2025

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The document is a Medical Records Release Form that authorizes the release of a patient's confidential health information to a specified physician or clinic. It outlines the patient's personal details, the limitations on the information released, and the reasons for the release. The form emphasizes the confidentiality of medical records, conditions under which treatment or payment may be affected, and includes provisions for revocation of authorization. It also states that the authorization expires after 180 days unless revoked earlier.

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