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I have this questions about mythehealth information I can contact the authorized individual or orga sclosure. Consent for Release. pg1of2. ihrlsinfo. docx Revised 09/2011 Printed name of patient Date AFFIX PATIENT LABEL HER Time Person Making Contact Comments. BIRTH SSN - - RECORD The following organization is authorized to make disclosure of my Consent for Release of Medical Information Mammography Reports and/or Images PATIENT NAME PHONE NAME PHONE DATE OF BIRTH SSN STATE ZIP MEDICAL RECORD...
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