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3385 Naaman School Rd., Garland, TX 75040
1208 Village Creek Dr. #104, Plano, TX 75093
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Home » Patient Forms » Authorization to Release Medical Records

Authorization to Release Medical Records

Authorization to Release Medical Records

  • Date Format: MM slash DD slash YYYY
  • I hereby authorize Vision Source Garland to release my medical records from ____________________. I understand and agree that health information about me, which is used or disclosed pursuant to this authorization, may be subject to re-disclosure by the recipient and may no longer be protected by law.
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