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Robert W. Java, M.D. & J. Collin Harder, M.D. AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATIONPatient Name: Chart# Address: City ST ZIP Date of Birth: Today's Date: As required by the
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The Jacey, M is a fillable form in MS Word extension needed to be submitted to the required address in order to provide certain information. It has to be filled-out and signed, which can be done manually, or with a particular software e. g. PDFfiller. It allows to fill out any PDF or Word document directly from your browser (no software requred), customize it according to your needs and put a legally-binding e-signature. Right after completion, user can send the Jacey, M to the relevant person, or multiple individuals via email or fax. The editable template is printable too because of PDFfiller feature and options proposed for printing out adjustment. In both digital and in hard copy, your form should have a clean and professional appearance. You may also turn it into a template to use it later, so you don't need to create a new document over and over. All that needed is to customize the ready template.

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