Get UMC MRU00695 2016
D Rec #: Page 1 of 1 Patient’s Name: Date of Birth: SS # (optional): Street Address: City: State: Phone #: Alt. #: Zip Code: Email Address: I authorize the following facility(ies) to release my Protected Health Information (PHI) for the specified dates of service: University Medical Center of Southern Nevada main hospital campus (UMC) Dates of Service: UMC Quick Care† (specify locations): Dates of Service: † UMC Primary Care (specify locations): Dates.
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