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INDIANA UNIVERSITY SCHOOL OF DENTISTRY Authorization for Release of InformationPATIENT NAME:LASTFIRSTMIMAIDEN OR OTHER NAMED ATE OF BIRTH: LAST 4 DIGITS OF SSN CHART #:MODAYYRADDRESS:CITY:STATE:ZIP:DAY
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Cert total protection 20 is a form used to report information about an individual or entity's total protection coverage.
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