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D. FACS Phillip M. Gilson M. D. FACS Michael K. Zenni M. D. FACS Todd D. Renschler M. D. FACS Thomas M. 920 S. Hebron Ave. Evansville IN 47714 Phone 812 473-1111 Fax 812 485-2461 Authorization to Release Information Bill J. Samm M. Gadient M. D. FACS Michelle A. Boger M. D. FACS TO WHOM IT MAY CONCERN This will authorize Fill in name of person and facility who is to release information To release information contained on my medical record including all treatment records. Purpose or need for...
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