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2016-11-8 · Proxy Access Form (Adults 18+) Page 1 of 2 SUTTER HEALTH USE ONLY MRN: _____ Department / Care Center: _____ Patient ID Verified By: _____ Physician Name: _____ SUTTER HEALTH USE ONLY MRN: DOB: Doc Type: DOS: I Hereby Authorize the Use or Disclosure of my Health Information I hereby authorize the Sutter Health affiliate to grant access to all
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