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4126612802
FAX 4126618020Authorization for Release of Medical and/or Dental Records
I authorize the release of my health information, as described below
TO:FROM:Provider/FacilityProvider/FacilityAddressAddressCityStateZipCityTelephone/FaxStateZipTelephone/Patient
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What is fax 412-661-8020?
Fax 412-661-8020 is a fax number used for submitting documents.
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