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Personal Care Agency: | 3Care4U |
| Agency Address: | P.O. Box 1312, Manitowoc, WI 54220 | |
| Agency Phone Number: | 920-663-1225 | |
| Agency Fax Number: | 920-614-2004 | |
| Agency Email Address: | [email protected] |
By signing this form, I authorize you to release confidential health information about me, by releasing a copy of my medical records, or a summary of my protected health information to 3Care4U.