MRU00695 PHI Rel AuthEng01-29-19 2025

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The document is a Protected Health Information (PHI) Release Authorization form for patients at the University Medical Center of Southern Nevada. It allows patients to authorize the release of their medical records, specify the types of information to be disclosed, and designate recipients for this information. The form includes sections for patient details, consent for releasing sensitive health information, purpose of the request, and methods of disclosure. It also outlines patient rights regarding the authorization and provides locations for UMC Quick Care and Primary Care facilities.

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