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Release of Information Form I, (print name×, give permission for Advanced Therapy Solutions to release any information requested by the following person’s) or facilities for my child (print patient

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What is i print name give?

i print name give is a form used for reporting name and contact information.

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The purpose of i print name give is to ensure accurate record-keeping of name and contact information.

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The form requires reporting of full name, address, phone number, and email address.

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