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Get CL-PC-32 2013-2024

____ Work: (_____) -_________-_________ Cellular: (_____) -_________-__________ Address: ______________________________________________________________________________________________________________________ (Street / P.O. Box) (City) (State) (Zip) I hereby authorize Auburn University Medical Clinic (AUMC) to release information from my medical records as may be required or requested by my insurance company, employer, or any other persons liable to AUMC for payment of all or part of the charges.

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