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Get SSM Medical Group Request for Access to/Authorization for Use and Disclosure of Protected Health Information 2013-2024

________________ LAST FIRST MI MAIDEN OR OTHER NAME DATE OF BIRTH:_______-_______-_______ MO DAY YR ADDRESS:________________________________________________ CITY:_________________________STATE:________ZIP:_______________ DAY PHONE:________________________________________________ EVENING PHONE:____________________________________________ I HEREBY AUTHORIZE: NAME ADDRESS CITY, STATE & ZIP PHONE FAX TO DISCLOSE MY PROTECTED HEALTH INFORMATION TO: NAME Relationship ADDRESS CITY, STATE & ZIP PHONE .

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