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PO Box 36 508 West Central Ave Suite B Estherville Iowa 51334 P 800-592-0180 F 712-566-5229 www. championmind.org Authorization to Release Confidential Information Client DOB/Effective Date A. THE INFORMATION AUTHORIZED FOR RELEASE MAY INCLUDE RECORDS THAT MAY INDICATE THE PRESENCE OF A COMMUNICABLE DISEASE OR NONCOMMUNICABLE DISEASE. H. L. I agree that a photocopy and/ or fax of this form is acceptable and is to be considered as valid as the original but it must be individually signed by me...
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