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Get Authorization To Furnish Information Autorizaci N Para Dar Informaci N - Dads State Tx

Nombre del Solicitante o Cliente) (Name of Spouse) (Nombre del C nyuge) living at con residencia en (Address/Direcci n) do hereby authorize persons, organizations, or establishments having information or records concerning me/us (or) my/our circumstances, to furnish such information to a representative of the Texas Health and Human Services Commission. Exception: This authorization does not grant permission for my doctor or other health care provider to release my personal health informatio.

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