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Get ISU Authorization To Disclose Health Care Information 2020-2024

Ddress (including City, State, Zip): University ID# Date of Birth (MM/DD/YYYY) Phone #: Email Address: I hereby authorize written and/or verbal RELEASE of my healthcare information as indicated: Release Information FROM Release Information TO Name: Name: Address: Address: City, State ZIP: City, State Zip: Phone: Fax: Phone: Email: Fax: Email: Please send my records by: Mail Fax Secure Email INFORMATION REQUESTED: REASON FOR RELEASE: Immunizations/titers/TB.

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