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Get Form 1.3: Authorization Cancellation - Prime Therapeutics

E information about you that is currently on file with Prime Therapeutics. Parents or a legal guardian may sign for a minor unless the information being released is about: pregnancy, sexually transmitted disease, alcohol or drug abuse, abortion, hepatitis B shot, or mental illness of a minor. For these types of records, the minor must sign the authorization. How to Complete This Form This form must be complete and signed by: The person whose Autho.

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Keywords relevant to Form 1.3: Authorization Cancellation - Prime Therapeutics

  • executor
  • discontinue
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  • specify
  • disclosure
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  • documentation
  • hepatitis
  • premium
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