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Get University Of Utah Health Patient Authorization For Disclosure Of Protected Health Information 2016-2024

Zip: Approximate Dates of Treatment: Information to be Disclosed: I authorize the following health care provider(s) to DISCLOSE my patient information: University Hospital Huntsman Cancer Institute Neuropsychiatric Institute Other Please include the following information (circle to indicate your selection) Clinic/Office Visit Notes History and Physical Discharge Summary Immunizations Radiology/Lab Report Consultation Report Operative Report Emergency Reports Psychosocial His.

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