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If I do not sign this consent or later revoke it DDG and/or GEC may decline to provide treatment to me. The Notice of Privacy Practices provided by DDG and GEC describes such uses and disclosures more completely. I have the right to a list of the disclosures made by DDG and/or GEC of my protected health information. By signing this form I am consenting to allow DDG and/or GEC to use and disclose my protected health information to carry out treatment GEC all payment for medical services...
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