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406 W. NEWLY ST. ATKINSON, NE 68713 TELEPHONE 402 9252811 FAX 402 9252580 AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION PATIENT NAME ___ D.O.B. ___ ADDRESS ___ PHONE #MR # ___I hereby authorize

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Contactwest Holt Medical Services is a healthcare provider offering medical services in the West Holt area.

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