Received from: Nurse Practitioner Services of Michiana Street Address 55756 Reeves Dr City IN 46514 Send to (NPS will complete) blank Street Address Address Line 2 City State Zip
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THIS AUTHORIZATION SHALL EXPIRE 12 MONTHS FROM THE DATE EXECUTED UNLESS OTHERWISE SPECIFIED BY THE PATIENT:
NOTE: THIS AUTHORIZATION WILL NOT BE ACCEPTED UNLESS IT IS COMPLETED IN ITS ENTIRETY. A COPY OF THIS FORM WILL BE ACCEPTED IN LIEU OF AN ORIGINAL. A COPY OF THIS AUTHORIZATION IS TO BE GIVEN TO THE PATIENT OR PATIENT REPRESENTATIVE.