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Get Longmont United Hospital MRD-205 2011

____ I, ____________________________________, authorize __Longmont United Hospital _______________________ (Patient or Legal Representative(s)) (Name of physician / health care provider releasing records) to release information to: Name: _____________________________________________________ Phone: ___________________________ Address: ___________________________________________________ City, State, Zip _________________________ 1. _____ The following protected health care information; From the sp.

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