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Get MetroHealth Medical Center Authorization To Release Protected Health Information To Another Facility 2003

) STATE PHONE # ( METROHEALTH MEDICAL RECORD # ZIP EMAIL ADDRESS ) PLEASE SPECIFY THE PURPOSE OF YOUR REQUEST: r PERSONAL r MEDICAL TREATMENT r DISABILITY r INSURANCE r LEGAL r OTHER: (please specify) INFORMATION TO BE DISCLOSED FROM (check as applicable): 3. INFORMATION NEEDED r THE METROHEALTH SYSTEM r METROHEALTH RECOVERY.

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