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AUTHORIZATION FOR RELEASE OF MILITARY MEDICAL.pdf

OMB No. 3095-0039 Expires 07/31/2014 AUTHORIZATION FOR RELEASE OF MILITARY MEDICAL PATIENT RECORDS NOTE: Records Center personnel complete blocks ...  

AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR.pdf

AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION ... the Military Treatment Facility ... TRICARE Health Plan to release the information ...  

AUTHORIZATION FOR RELEASE OF INFORMATION -.pdf

AUTHORIZATION FOR RELEASE OF INFORMATION ... Branch of Military: ... Medical documentation dated/related to: Other ...   Down

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    AUTHORIZATION FOR RELEASE OF INFORMATION ... Branch of Military: ... Medical documentation dated/related to: Other ...

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    REASON FOR REQUEST/USE OF MEDICAL INFORMATION ... The Military Health ... provider/treatment facilitylTRICARE Health Plan to release the information described ...

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    Personal Use Continued Medical Care School Other: ... AUTHORIZATION FOR RELEASE OF INFORMATION General Author: Humana Government Business

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    REQUEST FOR AND AUTHORIZATION TO RELEASE MEDICAL RECORDS OR HEALTH INFORMATION. ... Release of Information Unit at the facility housing ... “Patient Medical ...

    www.va.gov/vaforms/medical/pdf/vha-10-5345-fill.pdf