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Get Elkhart General Hospital MR-2P 2014-2024

City: State: ZIP: DOB: / / Phone: Date(s) of Service: By signing below, I hereby authorize my health information, as more specifically described below, to be used or disclosed by Elkhart General Hospital. (This information is referred to as Protected Health Information ). I hereby authorize: Elkhart General Hospital, P.O. Box 1329, Elkhart, IN 46515-1329.

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