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Get UMHS 70-10015 2019-2024

ON TO RELEASE COPIES OF A MEDICAL RECORD (Patient Requests Information To Be Sent From UMHS) For Clinic Use Only: Records sent from Clinic please send form to Central Imaging Mailed Picked Up Faxed Date Received: Date Processed: Processed By: Forwarding Request to ROI for processing Please complete this form in its entirety so we can help you receive the information you are requesting. 1. 1. This.

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