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The person or agency to whom information is disclosed may not redisclose this information unless I specifically consent to such redisclosures. AUTHORIZATION TO RELEASE INFORMATION RETURN FAX 847-240-2418 Patient s Name Birthdate Street Address City State Zip Maiden/Other Name Age Social Security Phone home work - I hereby authorize and Your doctor/therapist at PRA Name Person we are exchanging information with Address City State Zip Code Phone Fax to circle one or both release/receive...
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