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Get Scott & White Healthcare MR 4799 2012

Cord Number Street Address City, State Zip Telephone Number Please release this information to: Individual/Organization Name Street Address Telephone Number City, State Zip Fax Number I understand there is a charge for photocopies, as permitted by Texas law, unless copies are sent directly to another healthcare provider. □ I would like to review my record. Please release information from these hospitals or clinics: __________________________________________________ Please release the fo.

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