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AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION Patient: Date of Birth: Last First Other names under which the Patient has been treated: I authorize Preventative Health, LLC and its
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oformr names under which is a form used to report names and related information.
Anyone who needs to report names and related information must file oformr names under which.
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The purpose of oformr names under which is to collect and organize names and related information for record-keeping and regulatory purposes.
Information such as names, contact details, and any relevant identifiers must be reported on oformr names under which.
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