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Get Mr7350 2013-2024

Gned, 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 following: (Please check information to be released) The medical records to be released may contain medical information pertaining to mental health services, drug and/.

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