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5555 Peachtree Dunwoody Rd NE, Suite G65  Form

5555 Peachtree Dunwoody Rd NE, Suite G65 Form

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Notification must be provided to the Practice s Privacy Official / Committee at the address provided on this document. I understand the information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by Federal or State privacy regulations. 5555 Peachtree Dunwoody Rd NE Suite G65 Atlanta GA 30342 Fax 678 539-6570 Name First Middle Date of Birth Request for Access To and Authorization for Use and Disclosure of Protected Health...
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