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Get Avera Health 8610-31 2019-2023

Protected health information (PHI) about you. As stated in our notice, the terms of the notice may change. If we change our notice, you may obtain a revised copy by contacting the Privacy Office at Avera. By signing this form, you acknowledge that you have received a copy of our Notice of Privacy Practices dated March 1, 2017. Signature of patient: Printed name of patient: Sign.

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