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Physician noting down symptoms of a patient

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Diagnosis Letter

Name: Diagnosis Letter
SKU: 945
Price: 20.00 USD
Availability: InStock

$20.00 10 minutes

Full Name *

Email *

Phone Number *

Please remove dashes from the phone number entered.

Address *

What was your original diagnosis? *

Medical Records Release Form

By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary or narrative of my protected health information, to the physician/person/facility/entity listed below.

Patient Name *

The information you may release subject to this signed release form is as follows:

Complete Records

Care Plan

Pathology Reports

Hospital Reports

History & Physical

Lab Reports

Treatment Record

Medication Record

Progress Notes

Radiology Reports

Operative Reports

Other (Please Specify)

Release of Health Information

Release my protected health information to the following physician/person/facility/entity and/or those directly associated in my medical care:

Name *

Address: *

Signature (Type Full Name) *

I accept the terms & conditions

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Category: Services

Description
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Please ensure that you provide a correct address as the company is not responsible for undeliverable addresses.

*PLEASE NOTE: Although you are booking a 10 minute appointment, you will not be seeing the nurse again. Your original provider/nurse will email your documentation letter once the request has been made.

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Diagnosis Letter

Medical Records Release Form

Release of Health Information

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