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RADIOLOGY LTD., P.L.C. and RLC, LLC 677 North Wilmot Road Tucson, Arizona 85711 AUTHORIZATION FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION Patients Legal Name: Address: City: DOB Zip Code:

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Medical professionals specializing in radiology, such as radiologists, radiologic technologists, and radiology assistants, may require radiology ltd for their practice.

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