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I reserve the right to revoke it at any time. I understand that to revoke this consent I must provide written notice to Central Texas OB/GYN Associates. 7718 Wood Hollow Drive Suite 103 Austin TX 78731 P 512-279-6701 F 512-279-6750 www. centexobgyn.com Release of Protected Health Information Patient Name DOB I grant permission for my healthcare provider and their representatives of CTOA to discuss my care as it becomes relevant using this disclosure form to share information about my...
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