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Jason Wexler, M.D. 2641 S Wayne CT Arlington, VA 22206 Office: 4109290373 AUTHORIZATION TO RECEIVE OR DISCLOSE PRIVATE HEALTH INFORMATION Patient Name: ___Date of Birth: ___I hereby authorize the
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How to fill out 410-929-0373 authorization to receive
How to fill out 410-929-0373 authorization to receive
01
Fill out the personal information section with your full name, address, phone number, and email.
02
Provide any additional contact information requested, such as an alternate phone number or email.
03
Read and agree to the terms and conditions of the authorization to receive.
04
Sign and date the form to certify that the information provided is accurate and that you agree to receive the specified communications.
Who needs 410-929-0373 authorization to receive?
01
Anyone who wishes to receive communications or information from the specified source would need to fill out the 410-929-0373 authorization to receive.
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