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Get Dedicated To Women ObGyn Authorization For Release Of Protected Health Information_DSA

E disclosed: please print Name: Birth Date: Address: City/State/Zip code: Phone Number: Social Security Number: Section 2: Person or Entity that has protected health information TO BE RELEASED: please print the name of the facility that has the records to be disclosed: e.g. Dr. Jane Doe, XYZ Ins. Co., ABC Women s Health Dedicated to Women OB-GYN OR Name/Facility: 200 Banning Street, Suite 320 Address: Dover, DE 19904 City/State/Zip code: Phone: (302) 674-0223 Phone Nu.

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