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Release of Information

Need your records sent to our clinic or do you want your records from us sent somewhere else? Please fill out this form and our dedicated records administrator will make sure to take care of the rest!

Northern Neurology

Release of Information

Date of birth

I are hereby authorized and requested to disclose and give copies to / from Northern Neurology, to include any and all records and information concerning the above mentioned.

I understand that this information is protected by law and cannot be released/requested without my written consent unless otherwise provided by law. I further understand that this consent may be revoked by me, in writing at any time, except if the information has already been released or obtained.

Please Send
Date and time
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Wasilla Clinic

3505 E Meridian Park Loop Ste 100

Wasilla, AK  99654

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Fairbanks Clinic

1405 Kellum, Ste 100

Fairbanks, AK 99709

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contact our clinic via email at :
letstalkbrains@akneuronorth.com

or for Far North Infusion, please use:
cozyandinfused@akneuronorth.com

CALL

Tel: 907-864-0022

Fax: 800-654-6250

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