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Ion This form is an authorization that will permit UAMS Hospitals & Clinics to release your medical information to your designated adult proxy. Please read it carefully. Patient Name (last, first, middle initial) Social Security Number: Date of Birth: I am requesting that (insert name of proxy) receive access to my health information that is available in my UAMS Hospital & Clinics MyChart Record. This person is my designated MyChart proxy. I authorize UAMS.
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