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Get Form Shc Mr 1993

The fee covers clerical costs as well as any/all costs associated with copying of the information. SHC-MR-1993 Rev. 2-02-12 page 1 of 2 Please complete the reverse side of this form 1. Authorization I authorize disclosure of medical information and health records as described below Name of Patient / Telephone Record Holder s Name Address City State Zip Records Released To 2. Information to be Released for these Dates of Service From To HIV Test R.

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