• AUTHORIZATION TO DISCUSS MEDICAL INFORMATION

  • I hereby authorize you to use or disclose the specific information described below, only for the purposes and parties also described below.

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  • Information to be given to:

  • By signing this authorization, I acknowledge that I have read the REVERSE side and I release the above institution(s) and/or person(s) from legal responsibilities or liability that may arise from this act.

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  • Should be Empty: