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Chad Cleverly, O.D. Justin Denison, O.D. Amanda Moore, O.D. 3293 N Milwaukee St Phone: 2083222020 Fax: 2083221192 I acknowledge I have reviewed/been given the opportunity to review the Notice of Privacy Practices. (Copy available upon request.) I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services. I request that payment of
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