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Signature of Patient or Legal Guardian MR-SHS to Another Provider-2015 Date considered as valid as the original. address indicated above in writing and this authorization will cease to be effective on the date notified except to the extent action has already been taken in reliance upon it. Information to be released Identify dates and specific request From To Dates Lab report History and physical exam X-ray report At the request of the individual Other I understand that this health...
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