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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION 55 WEST TIBETAN (509) 5253720 (800) 2286053 WALL, WASHINGTON 99362 (509) 5256897 FAX Patients Name: MR #: Address: Telephone #: Previous Name(s): Birth
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55 West Tietan 509 is a form used to report certain financial information to the government.
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