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Irth: Patient Address: Reason Code DWC - Dissatisfied with care MOA - Moved out of area INS - Insurance changed COC - Continuation of Care PLS - Provider left Steward IST - Internal Steward Transfer OTH - Other reason Home Phone: City: State Zip: Work Phone: Release Information To I hereby Authorize Steward Health Care Systems to release my medical record information to / obtain information from: Name/Facility: Attention: Address: Phone: City: State Purpose of Request: Personal Z.

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