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Authorization Form for Release of Confidential Health Information to Diamond Headache Clinic Ltd I hereby authorize: Name of health care facility, physician, agency, etc Street address, City, state,
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How to fill out streetaddresscitystatezipcode:
01
Start by entering your street address, including any apartment or unit number.
02
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Enter the abbreviation for your state (e.g., CA for California) in the appropriate space.
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Input your zip code, which is a numerical code used for postal purposes, in the designated field.
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Individuals or households filling out official forms or applications that require a physical address may need to provide streetaddresscitystatezipcode.
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