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Please send a copy of this form with your medical records Great Falls Clinic 29th Hospital Street South Great Falls MT 59405 406 771-3106 Surgery Center 15th 1509 29th St. South 406 771-3538 Ave South 406 216-8070 AUTHORIZATION FOR RELEASE OF INFORMATION PROOF OF IDENTIFICATION IS REQUIRED TO OBTAIN RECORDS Name of Patient DOB Address Phone City/State Zip I HEREBY AUTHORIZE MY PROTECTED HEALTH INFORMATION TO BE RELEASED TO Facility/Provider FROM DATES OF SERVICE to MAIL PICKUP FAX REASON...
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