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2820 Mount Rushmore Road Rapid City SD 57701 Tel 605-342-3280 Fax 605-721-8435 AUTHORIZATION TO RELEASE HEALTH INFORMATION Request Records FROM Release Records TO Name Facility Address Street or PO Box City State Zip Phone No. Fax No. Medical Records of Patient Information Patient Name Last First Date of Birth MI Daytime Telephone Number - Address Covering the date s of service FROM Month/Year Purpose At the Request of the Patient Information to be disclosed Continuing Care TO Attorney Other...

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