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Patient LabelAUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION Patient Name Date of Birth please print By signing below, I authorize Center for Primary Care, (CPC) to use or disclose

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How to fill out by signing below i

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By signing below I refers to a declaration or confirmation statement made by an individual or entity that affirms the accuracy and truthfulness of the information provided in the associated document.

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