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3430 N High Street Olney MD 20832 301301-570570-7500 Fax 301301-570570-7504 office olneycounseling. Patient Name DOB Clinician of Olney Counseling Center LLC The purpose or need for the exchange and disclosure of this information is to check all that apply Facilitate Treatment All Healthcare Information Summarize Treatment Medical Records Coordinate Continuing Care Other please state purpose clearly I authorize the release of any records regarding drug alcohol or mental health treatment for...

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