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CONSENT FOR COMMUNICATION OF PROTECTED HEALTH INFORMATION TO PERSONAL REPRESENTATIVES Patient Name: Address: City, State & Zip: Telephone Number: Date: Race: Language Ethnicity Black or African American
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Do not discuss my is a statement or instruction indicating that certain information is private and should not be shared with others.
People who want to keep certain information private and confidential are required to file do not discuss my.
To fill out do not discuss my, simply write or type the statement 'do not discuss my' followed by the specific information that is not to be shared.
The purpose of do not discuss my is to protect sensitive or private information from being shared with others.
Any information that the individual wants to keep private and confidential must be reported on do not discuss my.
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