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Get and Sign North Texas Infectious Diseases Consultants, PA 3409 Worth  Form

Get and Sign Infectious Diseases Consultants Form

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Information is not a health care provider or health plan covered by federal privacy regulations the information described above may be re-disclosed and no longer protected by these regulations. NORTH TEXAS INFECTIOUS DISEASES CONSULTANTS P. A. AUTHORIZATION TO USE AND/OR DISCLOSE HEALTH INFORMATION I patient name authorize North Texas Infectious Diseases Consultants Check ONE box to GET records from Address and/or Phone number to SEND records to For the following purpose patient s request...
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