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Get For Official Use Only - Rush University Medical Center - Rush 2015-2024

INSTRUCTIONS: This authorization is made by you for the release of your healthcare information, as indicated. Please address questions about this form to: Rush University Medical Center, ATTN: Health Information Management Office, 1611 West Harrison Street, L1, Suite 001, Chicago, IL 60612, Telephone: (312) 942-7262, Fax: (312) 942-2264. FORM MUST BE COMPLETED IN ITS ENTIRETY. PATIENT INFORMATION: Patient Name Maiden Name.

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