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Get NY EBD-543 2017-2024

TE: 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 information to be disclosed is a child under the age of 18; or • A personal representative of the individual as designated through a Power of Attorney, Health Care Proxy, a court order, or other appropriate legal documentation. .

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