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(317) 844-5656

Serving the Indianapolis area with
excellence in hearing healthcare.

12065 Old Meridian Street
Carmel, IN 46032

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PROTECTED HEALTH INFORMATION RELEASE
I request that disclosure of my PHI (including name, diagnosis, test results, pathology, prognosis, and dates of service) be released to the following individual(s):

(Please note, your physicians do not need to be listed.)

Uncompromising Care Since 1977

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