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RELEASE OF MEDICAL RECORDS I, ___DOB___Authorize: North Country Dental 22 Exchange St. Gotham NH 03581 reception@ncdnh.com Fax # 6034665791 To Disclose to: ___ ______X___ Recent Radiographs ___ Records

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Forms - Castillo and refers to the specific forms required by the tax authority for reporting income and expenses related to the Castillo and tax program.

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