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Authorization for Release of Medical Information

Patients Date of Birth
Month
Day
Year
Medical Provider
I hereby authorize Ageless Enhancements Med Spa to:
Obtain records
Release records

Medical Records can be mailed only. We cannot send files via email.

Information to be Released (check all that apply):

Dates of Service Requested:

To:
Month
Day
Year
From:
Month
Day
Year
Purpose of disclosure (check one):
Continuity of care
Personal use
Insurance/Legal
Other

Patient Rights and Acknowledgment:

- I understand that I may revoke this authorization at any time by providing written notice.

- I understand that revocation does not apply to records already released.

- I understand that records may include photographs and/or sensitive information related to cosmetic

treatments.

- I understand that once released, the recipient may not be subject to federal privacy regulations.

- This authorization will expire one year from the date signed unless otherwise specified:

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Date of signature
Month
Day
Year
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