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Release of Medical Information to Another Facility Form

Release of Medical Information to Another Facility Form
Address *
Address
Line 1
Line 2 (optional)
City
State/Province
Zip/Postal
Authorize Records Released To: *
Authorize Records Released To:
Name
Address
City
State/Province
Zip/Postal
From Date
To Date
Records To Be Released: *
Release Records From: *
IF RECORDS ARE 20 OR MORE PAGES, THERE WILL BE A CHARGE OF $0.35 PER PAGE PLUS POSTAGE. PREPAYMENT IS REQUIRED.
This authorization will expire one year from signature date. I understand that I may revoke this authorization at any time by providing my written revocation. This release is executed in conformity with Wis. Stats. §§146.81-83, 51.30, 252.15 and 102.13.