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The faculty practice of the John A. Burns School of MedicineAUTHORIZATION TO RELEASE
PROTECTED HEALTH INFORMATION
Patient
Information:Patient Name
Date of BirthRecord Holder:Name of Clinic/ Provider
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What is form faculty practice of?
Form faculty practice is used for reporting income earned from faculty practice plans or clinics.
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Faculty members who earn income from faculty practice plans or clinics are required to file form faculty practice.
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