Alabama Medical Release Form 1
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ART FERTILITY PROGRAM OF ALABAMA
Kathryn L. Honea, M.D.
Virginia L. Houserman, M.D.
Cecil A. Long, M.D.
M. Chris Allemand, M.D.

MEDICAL RELEASE FORM
Date of Initial Appointment:____________________________________________________________
Patient Name: _________________________________________________________________________
Patient DOB: _______________________________ Patient SS#: ________________________________
Referring Physician: ____________________________________________________________________
Address: ______________________________________________________________________________
I hereby authorize the physician listed above to disclose my health information to:
Honea, Houserman, Long & Allemand P.C.
Suite 508
2006 Brookwood Medical Center Drive
Birmingham, Alabama 35209
Fax: 205-870-0698
Please send the following information:

Dates of service : From __________________ to _________________

Specific Records: _______________________________________________________

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