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Get Mayo Clinic MCS7602 2011

Ber I hereby authorize Mayo Clinic Arizona (“Mayo Clinic”) to disclose the following Protected Health Information pertaining to the above-referenced patient to: q Mail q Pick-up at Name of Person or Entity q Clinic (E. Shea Blvd) Address q Hospital (56th/Mayo Blvd) q Date/Time City, State, Zip Code Purpose for release of information: q Personal q Continuing Patient Care q Other Information being requested, please specify (i.e., Physician/Provider/Service or Dates of Service .

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