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INFORMED CONSENT FOR TREATMENT Please Inpatient Name: Date of Birth: LastFirstI request and authorize Braille Kelly, L. Ac., Dial. O.M. and/or Megan Berry Swell L. Ac., Dial. O.M., and/or Art ashes
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I Request and Authorize is a form used to authorize the release of personal information or to grant permission for specific actions related to personal data.
Individuals who wish to authorize the release of their personal information or grant permissions related to their data are required to file the i request and authorize form.
To fill out the i request and authorize form, provide accurate personal information, specify the information to be shared, indicate whom it should be shared with, and sign the document.
The purpose of the i request and authorize form is to facilitate the authorized sharing of personal information while ensuring the individual's consent is documented.
The form must report personal identifiers, the specific information to be disclosed, the recipient of the information, and the consent of the individual granting permission.
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