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Authorization for 1215 East Michigan Avenue Disclosure of

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This information may be used and disclosed for the following purposes Patient use Marketing use Other use Attorney use Fundraising use 5. NO Indicate the form and format which you would like to receive your requested information. Paper copy Electronic copy e.g. CD Other 8. However the revocation will not be valid if Sparrow Health System Hospital or has taken action in reliance on this of the signature below. If this Authorization permits the use and disclosure of my PHI for marketing purpose ...

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