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Get NY EBD-543 2011

Surance Program (NYSHIP) and New York Public Employee and Retiree Long Term Care Insurance Program (NYPERL) Authorization for Release of Health Information (w) EBD-543 (3/11L) AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION NOTE: The only persons who can complete and sign this form to authorize the disclosure of personal information are: The individual who is the subject of the information to be disclosed; A parent or legal guardian - only if the individual who is the subject of the i.

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