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MARSHALL MEDICAL CENTERAUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION Patient Name:Date of Birth:I hereby authorize:To release my health information to:(Person/facility to release health information)(Person/facility
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Obtain a registration form from Marshall County Exceptional Center.
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Individuals with exceptional abilities or disabilities who require specialized care and services.
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Marshall County Exceptional Center is a facility that provides specialized services for individuals with exceptional needs in Marshall County.
The administrators or designated representatives of Marshall County Exceptional Center are required to file the necessary reports.
To fill out Marshall County Exceptional Center reports, the administrators or designated representatives must provide all required information accurately.
The purpose of Marshall County Exceptional Center is to provide specialized services and support for individuals with exceptional needs in the community.
The reports for Marshall County Exceptional Center must include information on the services provided, number of individuals served, and any changes in programs or funding.
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