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AUTHORIZATION TO OBTAIN OF RELEASE PROTECTED HEALTH INFORMATION
Rainbow Kids Clinic
111 Otis Smith Drive Clarksville, TN 37043
Phone:931-553-6666 Fax 931-553-4006







of Protected Health Information of:







OR







111 Otis Smith Drive, Clarksville, Tennessee 37043 ♦ Phone: 931-553-6666 ♦ Fax 931.553.6681 ♦ Email: info@rainbowkidsclinic.com