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Get UK HealthCare CO-0005 2014

ENT OR AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN THIS DOCUMENT VERIFYING AUTHORIZATION FOR THE USE OR DISCLOSURE OF THE PROTECTED HEALTH INFORMATION UNDER THE ABOVE STATED TERMS. Date If patient is unable to sign, secure consent of Legal Representative and indicate reason below: Minor Incompetent Deceased Proof of designation must be filed in the chart or sent with this request. CO - 0005 09/14 Signature of Patient Signature of Legal Representative and Relationship to Patient Sign.

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