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I hereby authorize Ellen L. Gamza LCSW LLC to release all information necessary to secure payment of benefits. Disclosure of confidential information may be required by your insurance carrier HMO/EPO/POS/PPO/Traditional or indemnity plan in order to process your claims. Or older Date Parent/Guardian Signature NOTICE TO RECEIVING FACIILITY You may not redisclose any of this information unless the person who consented to this disclosure specifically consents to such redisclosure. You will be...

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How to fill out ellen l

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Ellen L is a form that needs to be filed with the relevant authority to report certain financial information.

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