Get the free Please read the information on the reverse side before completing this authorization

*3ROI* 3ROI Please read the information on the reverse side before completing this authorization I hereby authorize the use or disclosure of my health information as follows: Name and address of persons/organizations

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Overall, anyone who needs to provide relevant and accurate information for a specific purpose or request may be required to fill out a please read form. It is essential to carefully read and complete the form to ensure that the information provided is correct and complete.

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