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Get mc 220

SP/DDSD (Internal use only) Name First Social security number Middle Last Date of birth (mm/dd/yyyy) PLEASE READ THE ENTIRE FORM, BOTH PAGES, BEFORE SIGNING. I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): OF WHAT: All my medical records; also education records and other information related to my ability to perform tasks. This includes specific permission to release: 1. All records and other information regarding my treatment, hospita.

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