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Get Hershey Medical Center Medical Release

Oratory Results Operative Report, Procedure Report Serial #/Product ID # for implanted devices Other (please specify what document and date of service) This consent is subject to revocation at any time except to the extent that the person who is to make the disclosure has already taken action in reliance on it. If you wish to revoke this authorization, you must do so in writing to the address at the top of this form, to the attention of the Director, Health Information Servic.

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