Get NY DOH-5032 2011-2021
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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