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De me with my own copy of the information requested below. Please circle preferred format: Paper Electronic Other: Disclose the information requested below to the following individual or organization: Name: Address: City: State: Zip Code: Phone #: Fax #: Email: Reason for Request: Specific description of information to be accessed and/or disclosed: Complete medical record (except for mental health and/or developmental disability, substance abuse, and/or HIV/AIDS-related information; must b.

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