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Get NAME DATE Of BIRTH PATIENT AT INTEGRITY Btw AND

PATIENT AT INTEGRITY btw AND Month/Year PLEASE CHECK ALL THAT APPLY: Medical Records (email) Billing Records (email) Medical Records (printed) Billing Records (printed) $10 $10 $25 $25 Release my information to another person: Attached is copy of Power of Attorney Attached is copy of Medical Consenter Payment Method: Check Cash TOTAL: Month/Year **If sending to a Medical Provider, their email address mus.

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