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Get Authorization To Use Image Form

Et Address Date of Birth (MM/DD/YYYY) City Phone Number State Zip Code I hereby authorize the use or disclosure of protected health information about the individual named above. I am: the individual named above (complete Section 8 below to sign this form) a personal representative because the patient is a minor, incapacitated, or deceased (complete Section 9 below) Section 2. Who Will Be Disclosing Information About the Individual? The following person(s) or entity may use or disc.

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