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Get LHI World Trade Center National Responder Health Program Medical Records Release

: Name of Sending Person/Organization: __________________________________________ Address: __________________________________________________________________ City, State, Zip: _____________________________________________________________ Phone Number: __________________________ Fax Number: _____________________ To Release To: Logistics Health Incorporated Attn: Records Management Department 328 Front Street South La Crosse, WI 54601 Phone: 877-498-2911 Fax: 608-793-2964 I request and authorize.

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