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Authorization For Release of Medical Information

Thomas Carmen MD and Associate, Village at Pine, 1500 Village Run Road Suite 308, Wexford, PA 15090, Telephone: 724-934-1900, Fax: 724-934-3388
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I authorize Thomas Carmen, MD and Associates to release my medical records to:
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The following information is to be released:
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Purpose:
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Patient / Guardian
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