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Address: City/State/Zip: Date of Birth: Phone Number: ( ) I understand that MyCare is an Internet application that supports patient access to portions of my electronic healthcare record, electronic communications and other online services. I understand that MyCare is NOT to be used in an emergency. I understand that certain medical information is protected by state and/or federal law, therefore my authorization is required before my parent/legal guardian can have access to this information.

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