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Get Cleveland Authorization Medical 2012-2024

0 Fax: 216/445-7589 Patient: ___________________________________________ SS#: ________-_______-____________ Clinic #: __________________________________________ Date of Birth: ______ /______ /__________ Telephone #: ______________________________________ Current Address: _______________________________________ City: _____________________ State: ______ Zip: ____________ Check mark all other facilities/entities records are to be released from: □ Cleveland Clinic Homecare Services □ Clev.

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