Medical Records Release

Authorization to Use or Disclose Protected Health Information

Information of Patient for Whom Authorization is Made
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Authorized Person to Disclose Protected Health Information
The patient named above authorizes health information to be requested and released to representatives of:

Arizona Ketamine Treatment and Research Institute & Dr. Lauro Amezcua-Patino
Phone (480) 626-2727
FAX (480) 868-2272

Signature

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