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Get Wellstar Authorization For The Release Of Protected Health Information 2012

FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION By signing this authorization, I authorize Doctor/Facility ___________________________________ to use and/or disclose certain Protected Health Information (PHI) to WELLSTAR NORTHWEST WOMEN’S CARE 2550 Windy Hill Road, Suite 115 Marietta, GA 30067 770-980-1818 770-980-1873 FAX ___________________________________ ___________________________________ (Phone number) ___________________________________ (Fax number) This authorization permits .

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