Free Medical Release Form 30Free Medical Release Form 30
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Louisiana Department of Health and Hospitals
Authorization to Release or Obtain Health Information
For Eligibility in Program Enrollment
(including paper, oral and electronic information)
Name:
Mailing Address:
City/State/Zip:

Request Date:
Date of Birth:
Medicaid ID# or

Social Security #:

I authorize:
Name:
______________________________________________________________________________
Mailing Address:
____________________________________________________________________________
City, State, Zip Code: _______________________________ Phone #:___________________

To Release Information TO OR To Obtain Information FROM
(Place an “X” in the box that indicates if the information is being released OR requested.
Name:
______________________________________________________________________________
Mailing Address:
____________________________________________________________________________
City, State, Zip Code:
________________________________________________________________________
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