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PROFESSIONAL CONSULTINGCLINICAL ASSESSMENTEDUCATIONAL MAPPINGPatient Name: Date of Birth: Address: Phone: AUTHORIZATION FOR RELEASE OF CONFIDENTIAL HEALTH INFORMATION I hereby authorize that such

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The Dirksen Center is for filing financial disclosure forms.

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Elected officials, candidates, and certain government employees are required to file the Dirksen Center forms.

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Information such as assets, income, liabilities, and financial interests must be reported on the Dirksen Center form.

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