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No I do not elect to have these prescriptions filled by Epic Care. Consent for Accessing Medication History Electronically/ Consent for Epic Care to Fill Prescription s 07/2017. 1. Name Caregiver Spouse Durable Power of Attorney Home Address Other Specify City State Zip I do not want my health information used or disclosed for any of the following purposes Page 1 of 1 Patient Name Date Of Birth Intake Questionnaire Reason For Visit Medical History Do you have or have you had any of the...
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