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St. Peter Medical Center, P. C Labeled Houri, MD Consents For Use/ Disclosure of the Health Information Patient's Name: Patient's Date of Birth: Patient's SSN: Notice to Patient: By signing this form,
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St. Peter Medical Center is a healthcare facility that provides medical services to patients.
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The purpose of St. Peter Medical Center is to track and report medical services provided to patients for record keeping and billing purposes.
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