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Get Lifebridge Health Mr7350-501-l 2003

Igned, hereby authorize ! to release copies of medical records to: ! to obtain copies of medical records from: ! Verbal release only of medical information to: ____________________________________ (___ Name of Person or Agency Phone Number _____________________________________________ Address ) ____ (__ City, State, Zip Code ) Fax Number The purpose or need for such disclosure is __________________________________________________ Dates of Service: is authorized to release the followi.

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