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Get WI DHS F-42016 2019

Person whose HIV test results will be released: 2. Name and address of organization that I am authorizing to release HIV test results: a. Name of Organization: b. Address of Organization: 3. Person(s) or organization(s) that I am authorizing to receive these HIV test results: a. b. c. 4. This authorization will expire on the following date OR when the following event takes place: a. Date of Expiration: b. Event: 5. Reason for signing release of confidential HIV test results form: I und.

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