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WebJan 29, 2024 · CSN: MRN: PROTECTED HEALTH INFORMATION (PHI) RELEASE AUTHORIZATION MRU00695 (01/29/19) Page 1 of 1 ORIGINAL: Medical or Billing Record COPY: Patient or Patient’s Legal Representative †See reverse for a list of locations Patient’s Name: Date of Birth: SS # (optional): Street Address: City: State: Zip Code: WebUnless you state otherwise, this authorization includes the release and disclosure of all medical records and information, including but not limited to, paper and electronic … free clipart cat silhouette
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