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ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM You may refuse to sign this acknowledgement but, in refusing Weill not be allowed to process
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You may refuse to provide certain personal information.
Individuals who are required by law to disclose certain information may be required to file.
You may fill it out by following the instructions provided by the relevant authority or organization.
The purpose may be to protect your privacy or comply with legal requirements.
You may be required to report information such as your name, address, and financial details.
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