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Get Straub Clinic & Hospital Form 91562 2004-2024

T, Honolulu, HI 96813 located at the following address to use or disclose my individually identifiable health information as described below. I understand that this authorization is voluntary and that this facility will not withhold treatment if I refuse to sign this authorization. Patient Name: Date of Birth: SSN: Other names I may be known by: Address: Telephone: Work: Home: Other: This authorization covers the services provided during the period of _ /____/ __ to _ (m m / d d / y y.

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