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(Please print and sign the following form only if it is applicable.) Julienne Lemon, LMHC1560 Boy son Road, Suite B Hiawatha, Iowa 52233 (319) 9812122Authorization to Release Information Client Name:
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Signatures on the following page are official endorsements from individuals associated with a specific document, confirming their agreement or acknowledgment of the contents.
Typically, individuals who are listed as authorized signatories or those responsible for the contents of the document are required to file signatures on the following page.
To fill out signatures on the following page, individuals should sign their names in the designated signature area, include the date, and print their names beneath the signatures if required.
The purpose of signatures on the following page is to verify the authenticity of the document and to acknowledge that all parties agree to the terms outlined.
Information that must be reported includes the names of the signatories, their signatures, the date of signing, and any titles or positions they hold, if applicable.
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