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(Place MR Label Here) MR#: Patients Name: Patients Date of Birth:Acknowledgment of Receipt of Privacy Notice By signing this form, you are only agreeing that you have received a copy of the UAMS Notice
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Mr. Label Here refers to a designated document or form utilized for specific reporting or compliance purposes.
Entities or individuals as specified by the governing body or regulations related to Mr. Label Here are required to file this document.
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