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Get Wellstar Patient Authorization for Use and Disclosure of Protected Health Information

Ervice. The provision of this information is optional. Patient Information (please print clearly): Last Name Street Address First Name Middle Initial Date of Birth Apt. #/P.O. Box # (Please include complete mailing address) City State (Month/Day/Year) Medical Record #/Social Security# (optional) Zip Code Primary Contact Number If we cannot reach you at the telephone number listed above, WellStar may contact you (including leaving messages) regarding appointments or normal lab resul.

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