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With the person s listed above. Information used or disclosed pursuant to the authorization may be subject to re-disclosure by the recipient and no longer be protected by the HIPAA. Description of the specific information to be discussed Appointment Date/Times Diagnosis Summary of Dental Record X-rays Medications Treatment Plans Other specify Patient Name Date of Birth Information to be given to Name Relationship Address Phone This authorization shall remain in effect from the date signed...
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151 Main Street is the address of a location or property.
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