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Get St. Luke's Hospital Mr 19b 2013

_____________________ MI Date of Birth Medical Record Number I hereby authorize: To Release Information to: (Individual name, facility/organization and address) Check one or both: St. Luke's Hospital St. Luke's Clinics Specify clinics using attached list. Information from ALL St. Luke's Clinics will be released if clinics are not specified. PURPOSE OF DISCLOSURE ( ) Continuing Care ( ) Payment of Claim ( ) School ( ) Worker’s Compensation ( ) Legal ( ) For Personal Use ( ) Other (specify.

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