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Write down the data in the Please complete all pages of this, Vanderbilt University Medical, Vanderbilt Psychiatric Hospital, PATIENT IDENTIFICATION, Name, Address, City, Previous Name, Patient Phone, Date of Birth, State, Zip, Social Security, I request and authorize Vanderbilt, and RELEASE RECORDS TO Where records area.

Be sure to identify the vital information within the Mail Pick up in person Fax, Same as above NameAgency Address, State, Zip, Fax, For Doctors or other HealthCare, INFORMATION REQUESTED Fees may, Is this request for psychotherapy, If yes this is the only item you, MEDICAL RECORD INCLUDES RECORDS, Vanderbilt, University Hospital, Monroe Carell Jr, Childrens Hospital at Vanderbilt, and Psychiatric Hospital Vanderbilt part.

The OTHER DEPARTMENT, The information to be released, Specific Date, specify, cid Payment Records, and Page of MC Rev box enables you to indicate the rights and responsibilities of each party.

End by reviewing the next areas and preparing them as required: PURPOSE OF RELEASE, ie FMLA, Other specify, h other health care provider as, Authorization for Release of, I understand that my medical, I also understand that if I do not, PLEASE INITIAL THE STATEMENT BELOW, and You must initial one I do do not.

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