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Request to Release Health Information State of South Dakota
EForms. State of South Dakota CONSENT FOR RELEASE OF INFORMATION I hereby give my consent to release the information described below about Patient/Participant Name Address City State Zip Phone Date of Birth To the following person s /entities Name Organization From the following person s /entities INFORMATION REQUESTED AND PURPOSE OF DISCLOSURE Medical/Clinical Demographic/Financial Business/Proprietary Adult Juvenile Other Other Specific Information Requested Specific dates for Information...
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