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PATIENT NAME: Date of Birth: MEDICAL RECORD NO. SOCIAL SECURITY NO. ACCOUNT # TREATMENT PERIOD FROM TO Authorization for Use or Disclosure of Health Information Completion of this document authorizes
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Provide your medical history, including any pre-existing conditions or allergies.
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Answer the questions regarding your current health status and any symptoms you may be experiencing.
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TL v Truman Medical is a legal case involving Truman Medical Center.
Certain parties involved in the legal case may be required to file TL v Truman Medical.
TL v Truman Medical may need to be filled out with relevant case information and details.
The purpose of TL v Truman Medical may be to document legal proceedings and outcomes.
Information related to the legal case and parties involved must be reported on TL v Truman Medical.
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