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Get and Sign Medical Record Release Form University of Utah Health Care Healthcare Utah 2006-2022
UUHSC makes pursuant to this authorization may include information regarding my participation in a substance abuse treatment program. 6. Signature of UHC Staff Member Printed Name and Employee ID SUBSCRIBED AND SWORN before me this day of 20. 4P Form - Authorization.doc Rev 06/07/2006 RELEASE OF INFORMATION Emergency Records Immunizations Operative Report 4. Name Please disclose the following information circle to indicate your selection History and Physical Treatment Plans Psychological...
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