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Get HI ID/DD PASRR2 2014-2024

Division I. Patient Last Name First Name MI Sex Medicaid # Present Address I II. HEREBY AUTHORIZE THE EXAMINiNG DEPARTMENT OF HEALTH AND PHYSICIAN OR MEDICAL FACILITY TO RELEASE TO THE ITS DESIGNEES ANY INFORMATION RELATED TO MY PAST AND PRESENT MEDICAL CARE AS WELL AS ANY INFORMATION RELATED TO SUBSTANCE ABUSE/PSYCHIATRIC/PSYCHOLOGICAL CARE AND HISTORY. Print Name of Patient or Legal Guardian Signature of Patient or Legal Guardian Date Mailing Address of Legal Guardian Print .

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