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Get Passive Scheda Giordano Michela Form

(503) 494-6970 ACCOUNT NO. MED. REC. NO. NAME BIRTHDATE Patient Identification Page 1 of 1 AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION ALL SECTIONS OF THIS FORM MUST BE COMPLETED OR THE AUTHORIZATION WILL NOT BE ACCEPTED. I authorize: (Name of person / entity/ facility disclosing information).

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