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AuthorizationtoDiscloseProtectedHealthInformation Theundersignedauthorizes: EmergeOrtho 915TateBlvdSE,Suite190Hickory,NorthCarolina28602 Fax:8288559496 toreleasemyhealthinformationasnotedbelow. ***Allsectionsmustbecompletedinorderforrequesttobeprocessed***PatientInformation.

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