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City/State/Zip Phone # Fax #* REQUIRED TO RECEIVE CONFIRMATION OF REFERRAL Provider signature Date Participant Consent for Release of Information (reflects the requirements of 45 C.F.R. 164.508 August 14, 2002) I, , give permission to my health care provider to release my name, Participant name phone number, and date of birth to the PERAFit weight management program at National Jewish Medical and Rese.

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