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AUTHORIZATION FOR RELEASE OF PATIENT INFORMATION This document provides the authorization for the release of information as indicated below. Information about you cannot be released to others without
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Individuals or entities who have a legal obligation to report the information requested on the form.
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The purpose of this document provides form is to collect and organize information for record-keeping or regulatory purposes.
The specific information to be reported on the form will vary depending on the purpose of the form.
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