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Get Dc4 711b 2016-2024

Gram making disclosure) to disclose to (Name of person(s) or organization(s) and address to which disclosure is to be made) Purpose of disclosure authorized herein: The undersigned hereby authorizes the inspection and release of copies of my medical records indicated below by the above-named health care facility/medical record custodian only to the above-named entity(ies) or persons or their agents. Indicate all of the records authorized to be inspected/released by initialing in the appropriat.

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