Delaware Authorization for Use or Disclosure of Protected Health Information Form
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University of Delaware, Student Health Service
Newark, DE 19716-8101
(302) 831-2226 Fax (302) 831-6407
AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH INFORMATION
PATIENT NAME___________________________________________________ UD ID #_____________________
TELEPHONE___________________________________ DATE OF BIRTH_________________________________
I hereby authorize the University of Delaware Student Health Service to release to:
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