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H) birthday. No access will be granted for patients between the age of 12 and 18. My signature certifies that I am legally authorized to access medical and health insurance information for the child listed. Only one adult may be designated as the account proxy for each child. Initial Proxy access to another adult patient s (i.e. a patient who is 18 years of age or older) medical records will only be permitted if that patient has signed a Patient Authorization for Release of Protected Informa.

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