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D. is not a contracted provider for Medicare Medicaid Oregon Medical Assistance Program OMAP Oregon Health Plan OHP Crime Victims or Labor and Industry. This authorization is valid until revoked in writing. SIGNATURE Date Print Name Relationship to Patient Specifically Protected Information My signature below authorizes the release of HIV-related test information Effective Date February 6th 2013. Neither I nor my heirs executors administrators successors beneficiaries or assigns will submit a...

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