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Get MI MC 315 2017-2024

Recipient. authorization at any time by sending a written revocation to the doctor hospital or other custodian of medical information. Date Signature Name type or print If signing as Personal Representative please state under what authority you are acting MC 315 6/17 Address City state zip Telephone no. Approved SCAO STATE OF MICHIGAN JUDICIAL DISTRICT JUDICIAL CIRCUIT COUNTY PROBATE Original - Records custodian 1st copy - Requesting party 2nd copy - Patient CASE NO. AUTHORIZATION FOR RELEASE OF.

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