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Get MI CHJ-121 2014

OF PATIENT) Information to be released from: Facility: Address: Information to be released to: Address SPECIFIC DATES OF INFORMATION TO BE RELEASED: Written Beginning Date: Organization (if applicable) Ending Date: Verbal SPECIFIC INFORMATION: Medical Dental Mental Health Complete Health Record Other – Specify: Purpose of Release: By signing this form I am attesting to the fact that the records I am requesting be released, and may include alcohol, substance 1 abuse, mental hea.

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