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All fields must be completed in order to fulfill your request Patient Name Date of Birth Provider s Name Recipient s Name Patient s Phone SSN may use last 4 digits Orthopaedic Physicians of CO Provider s Address Address 1 799 E Hampden Ave Suite 400 Recipient s Phone Englewood CO 80113 City State Zip Request Delivery Paper copy will be mailed if other arrangements need to be made please call medical records. This authorization will expire on the following This release shall expire 1 Year from...

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