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Check applicable box. Approved Disapproved State reason for disapproval 8. Summary of Private Medical Information Released* 9. Patient s Name and SSN* 3. Medical Treatment Facility Name and Location 4. Reason for Request. 5. Private Medical Information Sought Specify dates of hospitalization or clinic visits and diagnosis if known 6. Requestor s Name Title Organization and SSN* FOR USE OF MEDICAL TREATMENT FACILITY ONLY 7. Check applicable box. Requestor s Name Title Organization and SSN* FOR U ...

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