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Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

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Page 1: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 2: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 3: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 4: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 5: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 6: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 7: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 8: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 9: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 10: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

Page 11: Microsoft...NEW 1. Authorization: I authorize disclosure of medical information and health records as described below Name of Patient: Social Security Number: 2. Record-Holderu. (Optional)

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