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M.D. GLOBAL, LLC
Medical Records Release Form
Phone: (303) 931-2348
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Fax: (888) 817-2326
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familyservices@mdglobal-llc.com
I,
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being the legal next-of-kin to the Donor,
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Hereby authorize the release of all of the decedent's medical information such as hospital/physician records and autopsy reports to M.D. Global, Llc and its affiliates to determine their suitability for non-transplant medical donation.
Authorized Signature
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clear
Printed Name
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Date Signed
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Telephone Number
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Email Address
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Street Address
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City
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State
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Zip Code
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Witness Printed Name
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Date Signed
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