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Get LDSS 4863. Medical Information Release Form - Otda Ny

LDSS-4863 11/05 NEW YORK STATE OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE MEDICAL INFORMATION RELEASE FORM I authorize the release of any health related information about me and any members of my family for whom I can legally give authorization related to the provision of assistance and services and my ability to participate in work activities including employment by my Primary Care Provider any other health care provider or the New York State.

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