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Get CT F4918Eng 2019-2024

Ormation is to be used for purpose of: Personal use Insurance Eligibility/Benefits Social Security Card (Maiden/Other Name) Continuing care Legal Disability Workers Comp Other I hereby authorize Yale New Haven Health/Yale Medicine entity(ies) named below to: RELEASE information from my medical record TO: OBTAIN information FROM: Name: Phone: Address: City/State: Fax (optional): Zip Code: Email (optional): If medical records are being.

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