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Get Sutter Health Form SH-0009 2017

Atient Information (Tell us about the patient) Patient Name: DOB: MRN: Address: City: State: Zip: Phone: Email (optional): Type of Access Requested (Please check ONLY one) Paper Copy CD My Health Online Inspection Only Email (encrypted) Email (not encrypted) (Note: If you would like us to send information over email not encrypted, this increases the risk that information could be read by an unauthorized third party.) Other (must be agreed upon by the patient and provi.

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