Authorization to Release Information
My name is telephone number and I give my permission to release protected health information (including medication lists and diagnoses) to Philip Leung RPH, BCGP for the purpose of Medication Therapy Management. The following pharmacies and doctors are allowed to release information:
This authorization is effective starting and ending 60 days later.
HIPAA Notice of Privacy Practices has also been received by me.
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Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Authorization to Release Information
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