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Get Umich Domino's Farms - Cardiovascular Medicine Form 70-10056

________________  Mailed  Faxed Sent by: ___________________________________________ Name Title Clinic/Unit Information Received:  No  Yes - Date Received: ____________________ Received by: __________________________________________________ Name Title Clinic/Unit This authorization is voluntary. I understand that University of Michigan Health System (UMHS) will not condition treatment, payment, enrollment, or eligibility for benefits on my signing this document. Patient Name:__.

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