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START FORMPhone: 18004562255I. Authorization to Share Health InformationVUMUS0010 v7 06/21Patient InformationI have read and understand the Authorization to Share Health Information and agree to the terms.A Signature of patient or patient representativeFax: 18554743067DateIf signed by patient representative, please explain authority to act on behalf of the patient:MaleFemaleFirst nameLast nameAddressII. P atient Services and Marketing/Other Communications Authorization I
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