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Get NY DOH-5032 2011-2024

Information to be Disclosed Initials Records from alcohol/drug treatment programs Clinical records from mental health programs* HIV/AIDS­related Information 9.  If not the patient, name of person signing form:  10.  Authority to sign on behalf of patient: All items on this form have been completed, my questions about this form have been answered and I have been provided a copy of the form.  SIGNATURE OF PATIENT OR REPRESENTATI.

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