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consent form

TO RELEASE HEALTH INFORMATION

1. Patient Information
2. I am requesting health information be released from:

**Please email (encrypted) here: lisaamiles@ptpmn.org or fax (secure) here: 507-738-1963

3. I am requesting the health information be sent to:
4. Information to be released, please check all that apply
5. Reason(s) for releasing information (please check)
6. Patients Signature 

Thanks for submitting!

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