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Patient Disclosure Authorization Form

ITEM#: MEDF04 Size: 8 1/2 x 11"
We Recommend 
MEDF04-2 
50
200
You Pay: 
$18.96
$39.96
BENEFITS AND FEATURES
Protect your practice and avoid privacy disputes with this clear, step-by-step form authorizing release of patient information.
  • Personalization includes: Includes your imprinted practice name, address, and phone number, up to 5 lines. 2-part form provides a patient copy and a 2-hole punched permanent record.

CheckSimple
Phone: 1-866-588-1552
Email: Customer.Service@CheckSimple.com