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Get IWK Health Centre Authorization For Release Of Health Information 2016

Ice Van den Hof, TEST / TEST, Maureen Release of Information 5850/5980 University Ave. or email to: PO Box 9700 Halifax, NS B3K 6R8 Canada releaseofinformation iwk.nshealth.ca Tel: 902.470.8888 www.iwk.nshealth.ca 1. Dec/8/2012 r*ER0 145/2*r r*IWKAUREH*r Patient identification information: (please print) Given Name(s): Last Name: Date of Birth (dd/mm/yyyy): Previous Surname: Address: Phone Number: 2. I request: (please check one) To view the original record. 3. A copy of th.

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