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Get KY CHFS-305 2004

From records whose confidentiality is protected by federal law. Federal regulations, 42 CFR Part 2, prohibit you from making further disclosure of it without the specific written authorization of the person to whom it pertains, or as otherwise specified by such regulations. A general authorization for disclosure is not sufficient for this purpose. My signature below acknowledges that I have read, understand and authorize the release of my PHI Signature ___________________________________________.

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