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Get UConn Health HCH-551 2011

R obtain my individually identifiable health information as described here to the person/organization named below. I understand that this authorization is voluntary and that it may include information relating to AIDS, HIV infection, behavioral health services/psychiatric care, treatment for alcohol and/or drug abuse. PATIENT’S NAME: DATE OF BIRTH: ADDRESS: E-MAIL ADDRESS: CITY: STATE: ZIP CODE TO#: PHONE NUMBER: 2. Dates of Service 3. Information: to be disclosed or to be obtaine.

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