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THIS by: NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED Referred AND DISCLOSED AND HOW YOU CAN HAVE ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Full Legal Name: In 1996,Name:

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7. Complete each section of the notice accurately and clearly, providing all the required information.
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12. Retain a copy of the submitted notice and any accompanying documents for your reference.

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7. - Legal or medical professionals
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