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Reason for Parent Guardian Witness or Proxy s Signature Patient 13 or Younger Patient 14-17 Years Old Signer s Relationship to Patient FIELD USE ONLY RU ID REGION Patient Disabled Patient Deceased PROVID PID Health Insurance Portability and Accountability Act 42 U.S.C. 299c-3 c and 42 U.S.C. 242m d which provide that information that could identify me will not be disclosed unless I have consented to that disclosure. I also understand that once my information is released to the study it is no...
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