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Get MN Standard Consent Form to Release Health Information

___________________________ State ______ Zip code _____________________ Daytime phone __________________________ E-mail address (optional) _____________________________ Medical Record/patient ID number (optional) ____________________________________________________ 2 Contact for information about how this form was filled out (optional): I give permission for the organization(s) listed in section 3 permission to talk to: First name ___________________________________ Last name ________________.

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