New Patient Authorization Form

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Patient Authorization

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I authorize the Anchorage Radiation Therapy Center Staff to send and/or discuss my past, current, and future medical records to/with the following physicians and hospitals:

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Patient Authorization

I authorize the following individual(s) to discuss and/or request my medical issues/records on my behalf:

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Billing Records

I authorize the following named individuals to discuss my billing related information with the office and billing service staff:

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I understand that I have the right to revoke authorizations assigned above at any point in time with the understanding that any records released or information communicated prior to this revocation were duly authorized.

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