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Get NC DMA-5028 2003

RVICES SSN: ADDRESS: AUTHORIZATION TO DISCLOSE INFORMATION I voluntarily authorize and request disclosure (including paper, oral, and electronic interchange): OF WHAT: All my medical records; also education records and other information related to my ability to perform tasks. This includes specific permission to release: 1. All records and other information regarding my treatment, hospitalization, and outpatient care for my impairment(s) including, and not limited to: -- Psychological, psychia.

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