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Www2 Ncdhhs Gov Form
Hereby authorize any physician, hospital, or clinic that has treated or examined Print Name ______________________________, to provide information to the county social/human services agency about their Print Patient’s Name current or past health. This consent is voluntary and remains valid for a period of up to one year. I also understand I may cancel the consent at any time by contacting the agency. The cancellation does not affect information already shared. I also understand that I may...Show details
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