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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
Only One Per Request

is requesting that Serene Care Clinics, the practice identified above release health information (check one)


The purpose of the disclosure: (“Request of the Individual” is sufficient for patient-initiated releases


CONDITIONS AND NOTIFICATIONS

This authorization for release of information expires 12 months from the date of patient’s signature. You may revoke this authorization at any time by writing to the Office Supervisor at the address listed above. However, such notification will not affect any actions taken in reliance on this authorization prior to the time of receipt of the revocation. You may inspect or request a copy of the health information to be used or disclosed, consistent with federal law. This authorization is being given to the SCC SCH group practice identified above and to SCC and each practice and entity affiliated with it.

Note:

There may be a processing fee charged to the patient to cover labor, copying, and supplies used to reproduce medical records


Location

10806 Reisterstown Rd, Ste 1F 
Owings Mills, MD 21117

Make an Appointment

We operate by Appointments Only

Open Hours

Tuesday – Friday: 8:30am – 6pm
Monday & Saturday: 10am – 4pm

Call Us

410-204-2866