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SUSAN H. SQUIRES, MA, NCC, PCs Brass field Professional Center 2012 New Garden Road, Suite E Greensboro NC 27410 Phone: 3367087144 / Fax: 3362880517 CONSENT FOR RELEASE OF INFORMATION Please complete
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Provide your personal information accurately in the designated fields. This may include your full name, address, date of birth, social security number, and other identifying details.
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Review the consent terms thoroughly. Understand what information you are authorizing to be released, to whom it will be released, and the purpose for the release. Take note of any limitations or specific conditions mentioned.
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If applicable, specify the date range for which the consent is valid. This can help control the duration of the release and provide an expiration for the consent.
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susan-squires-consent-for-release-of-infodoc is a document that authorizes the release of information.
Anyone who needs to authorize the release of information is required to file susan-squires-consent-for-release-of-infodoc.
To fill out susan-squires-consent-for-release-of-infodoc, you must provide your personal information and specify the information you are authorizing for release.
The purpose of susan-squires-consent-for-release-of-infodoc is to ensure that information is only released with proper authorization.
The information that must be reported on susan-squires-consent-for-release-of-infodoc includes the specific information being authorized for release and any relevant details.
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2012 LPCS NCC Greensboro NC Brassfield SQUIRES photocopy herein continuity consistency expire disclose

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