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Directory Results for Authorization to Release Protected Health Ination Mayo Clinic Blood Donor Program - MC0072-87 - mayo to Authorization to Release Protected Health Ination Name (First, Middle, Last) Birth Date (Month, DD, YYY) Release Information From: Release Information To / Provide Authorization For: Creekside/Cherish Health Clinic, 320 Bawden St

Authorization to Release Protected Health Ination Mayo Clinic Blood Donor Program - MC0072-87 - mayo
Authorization to Release Protected Health Ination Mental Health Treatment I, Name of Patient/Client , whose Date of Birth is , authorize Tyler Beach, LCSW to disclose to and/or obtain from: the following information: Name of Person or
Authorization to Release Protected Health Ination Name (First, Middle, Last) Birth Date (Month, DD, YYY) Release Information From: Release Information To / Provide Authorization For: Creekside/Cherish Health Clinic, 320 Bawden St