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Get Excellus B-1565 2016-2024

Alcohol or substance abuse  Abortion  Mental health (excluding psychotherapy notes) Note: you must complete a separate form to authorize release of information related to HIV/AIDS. The NYS approved form can be found at http://www.health.ny.gov/diseases/aids/providers/forms/informedconsent.htm PART E: ACKNOWLEDGEMENT (PLEASE READ AND SIGN) I understand that: • I can revoke this authorization at any time by writing to the Health Plan at the address listed below except this revocation wo.

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