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Dr. Carolyn John Dr. Robert John Dr. Michael HigginbothamNotice of Privacy (HIPAA) SIGNATURE AUTHORIZATION FORM I AUTHORIZE THE RELEASE OF ANY DENTAL OR MEDICAL INFORMATION NECESSARY TO PROCESS MY

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wwwssagovpubsen-05-10087a special examination is required for individuals who are applying for or receiving Social Security benefits and need to provide evidence of their medical condition or disability.

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Anyone who believes they meet the criteria for such benefits and has been requested to undergo a special examination by the Social Security Administration may need to fill out this form.

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