MARYWOOD UNIVERSITY

Student Health Services

Medical Records Release Form

 

 

I,

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(print)

give Student Health Services permission to release the following information to:

 

Name:

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(print)

Complete address:

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Fax ( fax number must be verified).

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Information to be disclosed:

Purpose of disclosure:  

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Expiration date: ( may be revoked at any time by patient).

Signature:

Date:

Contact Number