Get Medcom Form 756 2004-2022
there may be instances beyond the control of the family and the health care provider where information may be lost or inadvertently exposed, such as during technical failures, acts of God, acts of war, and so forth. I understand that I have he right to revoke this authorization, in writing, at any time. By signing this form I acknowledge the privacy risks associated with using E-mail and authorize health care providers to communicate with me or any minor dependent/ward for purpose of medical ad.
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