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Get OK HIS.0006 2014-2024

________________________________ Social Security #:_____________________________ I hereby authorize _______________________________________________________________________________ Name of Person/Organization Disclosing PHI to release the following information to ________________________________________________________________ Name and Address of Person/Organization Receiving PHI Information to be shared: â–¡ Psychotherapy Notes (if checking this box, no other boxes may be checked) â–¡ Entire .

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