Med. Release Auth.
To: (Name of physician or facility):
I hereby authorize and request you to release the following medical records in your possession to:
Howard J. Lang, D.O., F.A.A.E.M.
Derek H. Lang, D.O.
Family Medicine, Allergy & Environmental Medicine
789 Lonesome Dove Trail
Hurst, TX 76054
Ph: (817) 577-0480 Fax: (817) 581-0167
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Document Name: Med. Release Auth.
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