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CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT GIVING CONSENT Name: Date of Birth: SECTION B: TO THE PATIENTPLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. Purpose of Consent:

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What is section b to form?

Section B of the form is where you provide additional information or details related to the main part of the form.

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Any individual or entity who needs to provide more specific information as requested on the form.

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You can fill out Section B by carefully reading the instructions provided on the form and providing the requested information in the designated spaces.

What is the purpose of section b to form?

The purpose of Section B is to gather additional details or specifics that are necessary for completing the form accurately.

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The specific information that needs to be reported on Section B will depend on the nature of the form and the instructions provided.

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