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Get and Sign OFFICE ONLY Date Recd Date Sent Form
Information may not be released or disclosed without my written authorization unless otherwise provided for by law. I also understand that if I authorize a third party that is not required to comply with such regulations to receive my health care information my information may be re-disclosed by that party and would no longer be protected. in my health care there may be a charge. Unless specifically excluded this authorization includes release of specially protected information requiring my...Show details
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