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person who acts as their Personal Representative. Use of their information is strictly limited to that purpose described below. I Section A: Member Information By signing this form in Section F, I understand and agree that Gold Coast Health Plan (GCHP) may release my personal health information as described below to the Personal Representative named in Section D below. See Section E for mailing address or Fax number. Member First Name: Member Last Name: Address: Telephone Number: Member ID.

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