Pennsylvania Medical Records Release Form
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DIAGNOSTIC CARDIOLOGY ASSOCIATES, P.A.

Patient Medical Records Release Form
Patient Name ________________________________________________________________ Date of Birth ____________________
Address ____________________________________________________________________________________________________
___________________________________________________________________________________________________________
Phone Number _________________________________________ Social Security Number _________________________________
I hereby authorize Diagnostic Cardiology Associates, P.A. to release/request the following information contained in my medical
records.
This is a ___ One-Time Disclosure ___ Continuous Disclosure for 12 months beginning _______________________________
All PHI including confidential All PHI except confidential selected below*
(*Note: While specific Confidential PHI will not be included, the information authorized for release may make reference to confidential findings.)

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