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Get UnitedHealthcare MRAMR2198EN 2012

Care Insurance Company (UIC), on behalf of itself and related companies, to release my personal health information, including medical, claim and/or benefit records, to . (Recipient s Name please print) These records may have information on specific treatment or services I have received. These records may have information created by others. This Authorization to Share Personal Information Form allows UnitedHealthcare Insurance Company (UIC), on behalf of itsel.

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