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Get Dch 1183

Ndividual's Name (Beneficiary, Recipient, Patient, Consumer, etc.) Individual's ID Number (Medicaid, SSN, Other) Street Address Individual's Date of Birth / City State ZIP Code / Phone ( ) - I AUTHORIZE THE MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES (MDHHS) TO SHARE MY HEALTH INFORMATION: List the amount or type of information you would like to share in the section below. For example, you can say all my health information or list certain types of information you would like to sh.

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