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Please print legibly This authorization will expire on the following Fill in the Date or the Event but not both. No then you may check as many items below as you need. All PHI in medical record Operative information Labor/delivery summary Admission form Cath lab OB nursing assess Dictation reports Special test/therapy Postpartum flow sheet Physician orders Rhythm strips Itemized bill Intake/outtake Nursing information UB-04 Clinical test Transfer forms Other Medication sheets ER information I...
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