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Get CT F4918WHIM 2005-2024

T for additional recipients. Send any obtained information to: NAME: PHONE/FAX: ADDRESS: CITY: INFORMATION TO BE RELEASED OR OBTAINED (IN EITHER VERBAL OR WRITTEN FORM) as follows: Dates of Service: Inspection Only Copy of Standard Report (includes, as appropriate, discharge summaries, operative notes, results of X-ray and lab tests and history and physical.) Copy of other Medical or Billing Information as specified: PURPOSE OF DISCLOSURE: Changing physicians School Other (please specify): .

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