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Authorization for Use or Disclosure of Protected Health Information
In order to authorize the release of your Protected Health Information (PHI), please download the form below, complete, sign, and return to:
Mercy Medical Center
Health Information Management
Attn: Release of Info Clerk
1301 15th Ave. West
Williston, ND 58801
Or fax to:
(701) 774-7468
Authorization Form
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