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Get Health Partners 18534 2020

By date form before submitting. Date Only 3. If signing for Patient: sign, date and indicate Release ID relationship to patient before submitting. AUTHR Instructions for completing and mailing this form are on page 2. Patient Information Patient name Previous last name (if any) Street address Date of birth City Who has the information you want released? Where do you want the information sent? Information to be sent (check only what applies) (see instructions on back of form) Special Pe.

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