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S AME D AY S URGI C ENTER OF O RLANDO P A T I E N T HIPAA A C K N O W L E D G M E N T A N D C O N S E N T F O R M Patient Name Date of Birth Patient initials Notice of Privacy Practices. The email that I authorize to receive email messages for appointment reminders and general health reminders/feedback/information is. I hereby permit practice and the physicians or other health professionals involved in the inpatient or outpatient care to release healthcare information for purposes of...
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