| PHI Authorization Form | |
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For records being transferred to another physician there is not a charge. For records being released into the patient's custody MPMPC applies the following formula: $1.00 per page up to twenty-five pages. .25 cents per page for each page greater than twenty-five. |
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Related Documents:
- PHI Auth Form Revised 0909.pdf
This is your authorization to request or release your medical records. Download and complete this form. Return it to your provider's office location for processing.
