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Get Los Robles LR0037 2014

handling the release of the records. Section A: This section must be completed for all Authorizations Patient Name: Birth Date: Patient's Phone: Last Four Digits SSN (optional): Provider's Name: Recipient's Name: Provider's Address: Address 1: Recipient's Phone: Address 2: City: State: Zip: Request Delivery (If left blank, a paper copy will be provided): Paper Copy Electronic Media, if available (e.g., USB drive, CD/DVD) Encrypted Email Unencrypted Email NOTE: In the event the facility is.

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