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Get River Crest Hospital Consent and Authorization to Release Information or Medical Records 2010-2024

MATION OR MEDICAL RECORDS UNDER THE PROTECTION OF FEDERAL LAW TITLE 42, CFR, CHAPTER 11, PART 11 PATIENTS NAME:_________________________________________________ SOCIAL SECURITY NUMBER_______________________________________ D.O.B________________ PHONE:__________________________________________ ADDRESS:____________________________________________________ CITY/STATE/ZIP:______________________________________________________________________________________________________________________ I, _______.

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