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No English Spanish Other Signature of Patient s Personal Representative/Parent/Requestor Date Please submit Form by Fax Number Mail Drop off Cleveland Clinic Attn My Chart Caregiver Area Ab 131 Basement of the A building Revised 7/24/13 FORM B AUTHORIZATION FORM PEDIATRIC Patient s Name Patient s Date of Birth / / Patient s Cleveland Clinic Patient s Current Street Address Patient s SS Patient s Telephone Name of...
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