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Get UMC MRU00695 2013

Cal Record #: Zip Code: Account #:  Mail  Call for pickup I authorize the disclosure of the above named individual’s Protected Health Information (PHI) and request: Name: Address: to release the requested information to: Name: Address: ► The purpose for this requested information is:  Healthcare Provider (Note: There is a $0.60 per page photocopy fee)  Personal Use  Attorney  Insurance  Other (specify): ► Date(s) of Services requested: ► The following info.

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