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Authorization to Release Medical Records

Complete the form below and submit to your healthcare provider.


This form should be downloaded and printed.

PATIENT INFORMATION

First Name: ______________________________


William Last Name: ___________________________
Briggs

Date of Birth (mm/dd/yyyy): __________________


07/12/1977 Phone: _______________________________
12035616448

Patient Address: _____________________________________________________________________


1454 Union Street

City: ____________________________________
San francisco State: ___________
CA Zip: ______________
94109

HEALTHCARE PROVIDER INFORMATION

The above patient is (or has been a patient of the following healthcare facility or provider:

Provider / Facility Name: ______________________________________________________________

Provider / Facility Phone Number: _______________________________________________________

Provider / Facility Address (Street, City, ST, Zip): ______________________________________________

The above patient authorizes the above healthcare facility/provider to release all medical records and to discuss health
information with the following healthcare facility/provider:

KLARITY CLINIC OF SOUTHERN CALIFORNIA


Dr. Devin Tang and Dr. Henry Liang
510 N. 13th Ave., Ste. 104
Upland, CA 91786
844.552.7489 / FAX 888.945.4264

I understand that release of medical records may include patient histories, office notes, and working diagnoses. It may
include drug, alcohol or substance abuse records, mental health records, procedural and surgical records, test results,
current and past medications and treatments. Authorization is valid for 90 days from the date of signature unless revoked
in writing. I have read and understand this consent and I have signed it voluntarily.

Patient Signature: _____________________________

Patient Name (printed): _________________________


William Briggs

Date Signed: _________________________________


28 October, 2024

Copyright © 2019 Klarity Consulting, LLC. All rights reserved.

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