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Get Credit Equifax Report Form

Re certain protected health information (PHI) about me with: Name Relationship This authorization permits Advocare to use and/or share with the individuals noted above any part of my individual identifiable health information, with the exception of information related to: Alcohol & drug use Sexual activity or sexually transmitted disease Pregnancy Other This information will be used to help me make appropriate medical care decisions with the assistance of my parent(s) or lega.

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