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CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY INSECURE MEANS I, AUTHORIZE Dawn A Dillon, M. Ed, LPC, NCC, 3108 W. 6th Street, Suite 207, Fort Worth, TX 76107, TO TRANSMIT THE FOLLOWING

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Who needs consent for transmission of?

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Any individual or organization that intends to transfer or transmit personal information to another party.

02

This can include companies, institutions, healthcare providers, research organizations, etc.

03

It is essential to obtain the consent of individuals whose personal information will be transmitted.

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