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Authorization for Release of Information

You must complete this form if you want Prime Therapeutics to share information about you with someone else (e.g., an agent or family member).

Note: Under the law, an authorization for use or disclosure of psychotherapy notes cannot be combined with an authorization of other health care information.

Member Information (person granting release of information)

I give my permission to release prescription or other medical information about me that is created or held by Prime Therapeutics LLC. This information may include my address, date of birth, membership status, and medical claim or prescription history. 

You may release this information to:

Purpose for this release*