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Get OR ORS 192.566

INFORMATION I authorize: _____________________________ (Name of person/entity disclosing information) to use and disclose a copy of the specific health information described below regarding: (Name of Individual) consisting of (describe information to be used/disclosed): to (name and address of recipient or recipients): for the purpose of (describe each purpose of disclosure or indicate that the disclosure is at the request of the individual): If the information to be disclosed contains any o.

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