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I understand that I may revoke this authorization at any time. Signature Date Please complete other side Updated 3/19/15 Briefly explain your issue and please state how you would like Congresswoman McCollum to help you. If your request for assistance involves medical information please fill out the Authorization to Release Medical Information under the Heath Insurance Portability and Accountability Act of 1996 HIPAA and return it along with this form. Veterans Affairs Issues Case Number...
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