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AUTHORIZATION TO USE AND DISCLOSE HEALTH INFORMATIONPatient Name: LastFirstMiddleDate of Birth: Home Address:, FL Phone Number: MY HEALTH INFORMATION TO BE DISCLOSED: By signing this Authorization,
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This authorization allows someone to act on your behalf and make decisions or perform tasks outlined in the authorization document.
The person who is granting the authorization is the one required to fill out and sign the authorization document.
To fill out the authorization, you will need to provide all the required information, sign the document, and have it witnessed or notarized, depending on the requirements.
The purpose of signing this authorization is to give someone else the legal authority to act on your behalf in specific situations or tasks.
The authorization document should include details of the tasks or decisions the authorized person can make, as well as any limitations or conditions specified by the grantor.
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