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Get Information Release Of Billinig Information Form

F.R. 2. 34 and 2. 35. Release of HIV/AIDS test results Health and Safety Code 120980 g. Release of genetic testing information Health and Safety Code 124980 j. EXPIRATION OF AUTHORIZATION Unless otherwise revoked this Authorization expires insert applicable date or event. If no date is indicated the Authorization will expire 12 months after the date of my signing this form. Print Name 756-020Z 04/03 Date Signature Patient Parent Guardian Time Re.

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