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This information may be disclosed and used by the following individual or organization Release To Family Centered Medicine LLC Address 4930 Overland Dr. Unless otherwise revoked this authorization will expire on the following date event or condition. If I fail to specify an expiration date event or condition this authorization will expire 1 year from the date signed. in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used or disclosed as...
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