adventist health | west coast and hawaii hospitalsp.o. box 3004 lodi, ca 95240 (209) 334-3411...

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Page 1: Adventist Health | West Coast and Hawaii HospitalsP.O. BOX 3004 Lodi, CA 95240 (209) 334-3411 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Page 1 of 2 F8700-50 (12/17)/112
Page 2: Adventist Health | West Coast and Hawaii HospitalsP.O. BOX 3004 Lodi, CA 95240 (209) 334-3411 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Page 1 of 2 F8700-50 (12/17)/112
Page 3: Adventist Health | West Coast and Hawaii HospitalsP.O. BOX 3004 Lodi, CA 95240 (209) 334-3411 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Page 1 of 2 F8700-50 (12/17)/112
Page 4: Adventist Health | West Coast and Hawaii HospitalsP.O. BOX 3004 Lodi, CA 95240 (209) 334-3411 AUTHORIZATION FOR USE OR DISCLOSURE OF HEALTH INFORMATION Page 1 of 2 F8700-50 (12/17)/112