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AUTHORIZATIONFORTHEDISCLOSUREOFPROTECTEDHEALTHINFORMATIONIhavereceivedNoticeofprivacypracticesfromRollerWeightLossandAdvancedSurgery (initial) Iherebyauthorizethedisclosureofmyprotectedhealthinformationtothefollowingnonhealthcarerelated
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