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Get Marshfield Clinic Release Of Information

/ / Patient signature Person authorized to consent for patient Relationship Date m/d/y Phone no. Send completed request to Release of Medical Information Marshfield Clinic 1000 N. Oak Ave. If Marshfield Clinic is unable to comply with my approved request for information maintained or accessible on-site within thirty 30 days it may extend the deadline for up to thirty 30 more days by notifying me in writing. Except as otherwise allowed under appli.

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