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Get Memorial Hermann 73115 2013

Tient Name Date of Birth Of Protected Health Information SS# Medical Records# Address Telephone # ( ) I hereby authorize Memorial Hermann Healthcare System to release my records from the following facilities (please check ONLY facilities that apply): HOSPITALS: ❏ Memorial City ❏ Northwest ❏ Southwest ❏ Northeast ❏ Sugar Land 921 Gessner Rd PH 713-242-3401 ❏ Hermann-TMC 6411 Fannin 1635 N. Loop West PH 713-867-4335 7600 Beechnut PH 713-456-5576 ❏ Katy ❏ Woodlands 23900.

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