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Get Centura Health Chcr-004 2011

Ate of Birth Last 4 of Social Security Number Address City, State, Zip Code Telephone Number I hereby authorize the Centura facility listed below to disclose/release the Protected Health Information specified in this request to the organization, agency or patient named. Release by: _____________________________________________________ Release to: _____________________________________________________ Centura Facility _____________________________________________________ Address ___________.

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