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Patients Name: Dates of Treatment: Address: (Street) (City) (State) (Zip)DOB:SS#:Phone:()I acknowledge and hereby consent to release information from my health record including psychiatric and alcohol/drug
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I understand that my is a statement or document that is used to affirm one's comprehension or acknowledgement of a certain topic or situation.
Anyone who needs to acknowledge or confirm their understanding of a particular matter may be required to file an i understand that my document.
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The purpose of i understand that my is to ensure that individuals acknowledge and confirm their comprehension of a specific topic or situation.
The information that must be reported on i understand that my may vary depending on the specific topic or situation being acknowledged, but typically includes the individual's name, date, and a statement of understanding.
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