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Get Sharon Regional Medical Center HM-1401G 2015-2024

If any field is left blank, the authorization will be considered defective. Patient’s Name Address Date of Birth City State Zip Telephone Number Medical Record Number Email Address I authorize the use and disclosure of health information about me as described below: Facility Authorized to Release my Health Information Address City State Zip Telephone Number State Zip Telephone Number Agency or Individual(s) Authorized to Receive my Health Information Address .

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