Rio Grande Medicine

Authorization to Receive/Disclose Protected Health Information

Patient Name *

Please enter patient name

Date of Birth *

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Provider/Facility Name *

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Phone Number *

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Address *

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Complete Medical Record

Laboratory Results

Imaging Reports

Medication List

Progress Notes

I authorize the release of my medical records as specified above. I understand this authorization is voluntary.

You must authorize the release of records

Digital Signature *

Date *

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