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Equestor s Telephone Number Please check the authorized party s relationship to the patient: Is there a court order or a restraining order in effect limiting the requesting individual s access to this child s medical records and information? Custodial Parent Legal Guardian ** Non-Custodial Parent Durable Power of Attorney for Healthcare (DPOA) ** Please Write: Yes/No If yes, please provide legal documents. **This request MUST be accompanied by a copy of le.

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