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By signing below I represent and warrant that I have authority to sign this document and authorize the use or disclosure of protected health information and that there are no claims or orders pending or in effect that would prohibit limit or otherwise restrict my ability to authorize the use or disclosure of this protected health information. When required I authorize Integr8 Health LLC providers to discuss my case with the above provider. O. and/or 170 US Route 1 Suite 200 Falmouth ME 04105...

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