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Ervice. The provision of this information is optional. Patient Information (please print clearly): Last Name Street Address First Name Middle Initial Date of Birth Apt. #/P.O. Box # (Please include complete mailing address) City State (Month/Day/Year) Medical Record #/Social Security# (optional) Zip Code Primary Contact Number If we cannot reach you at the telephone number listed above, WellStar may contact you (including leaving messages) regarding appointments or normal lab resul.

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Tips on how to fill out, edit and sign Wellstar Patient Authorization for Use and Disclosure of Protected Health Information online

How to fill out and sign Wellstar Patient Authorization for Use and Disclosure of Protected Health Information online?

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