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Get IWK Health Centre Authorization for Release of Health Information 2013

002 M Please complete form and fax to (902) 470−8851 or mail to Release of Information Office ER0000145/12 HCN: 22222222 Van den Hof, TEST / TEST, Maureen SCA,TEST Visit Dec/8/2012 r*ER0 145/2*r r*IWKAUREH*r Patient identification information: (please print) Given Name(s): Last Name: Date of Birth (dd/mm/yyyy): Previous Surname: Address: Phone Number: 2. I request: (please check one) ❑ To view the original record. 3. ❑ A copy of the original record/specific documents, noted .

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