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ALLFIELDSWITHA×REQUIRED *PatientName(s): *DateofBirth: *ContactPhone#:AUTHORIZATIONTORELEASEAND/OROBTAINPATIENTINFORMATION *Chooseonebelow: ObtainFrom:(Releasing facility)Released:(Receiving entity)UCCSHealthCirclePrimaryCareClinic:
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All fields with a refer to the sections or portions of a document that begin with the letter A.
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To fill out all fields with a, simply input the requested information in the designated spaces that begin with the letter A.
The purpose of all fields with a is to gather specific information and ensure that all relevant details are provided.
The information required to be reported on all fields with a will depend on the document or form being completed.
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