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Get MI CHJ-121 2017-2021

OF PATIENT) Information to be released from: Facility: Address: Information to be released to: Address Organization (if applicable) Written SPECIFIC DATES OF INFORMATION TO BE RELEASED: Beginning Date: Ending Date: Verbal (Date will be good for 1 year from date of signature unless otherwise specified) SPECIFIC INFORMATION: Medical Dental Mental Health Complete Health Record Other – Specify: Purpose of Release: Juvenile Lifer Resentencing Release By signing this form I am attest.

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