Missouri Medical Record Release Form 1
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TAYLOR HEALTH AND WELLNESS CENTER
Missouri State University
901 S. National Avenue, Springfield, MO 65897
Telephone: (417) 836-4000 Fax: (417)836-4133 http://health.missouristate.edu

AUTHORIZATION TO DISCLOSE/RELEASE OR OBTAIN MEDICAL RECORDS
All disclosures are in compliance with Federal and State laws, including the Health Insurance Portability and Accountability
Act of 1996 (HIPAA), governing the use and disclosure of Protected Health Information (PHI).
- --------------------------------------------------------------------------------I hereby authorize Taylor Health and Wellness Center to:
__disclose/release to
___obtain from
_____________________________________________________________________________________________________
(name of person or organization)
(telephone)
(fax)

_____________________________________________________________________________________________________
(address)
(city)
(state)
(zip)
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