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Appoint an Individual as your personal representative complete this form. I hereby authorize NORTHWEST OB/GYN to release the following protected health Name Relationship Spouse Other Relative Friend Other Date of Birth Personal Health Information That May Be Disclosed All personal health OR One or more of these choices Times of appointments Prescriptions ancillary equipment Test results Copies of medical records If you wish to designate more than one Individual use an additional form. I may...Show details
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