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Get Authorization To Release Health Information - Cook Children's

Signed and dated by an authorized person to be valid. I understand this authorization is voluntary, I may refuse to sign this authorization and I understand that CCHCS may not withhold treatment because I refuse to sign this authorization. 1. I authorize CCHCS (check ( ) one or more: medical record of: Medical Center Physician Name/Clinic Name: Home Health to release health information, as described below, from the Patient s Full N.

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