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Get Wa Form 126 2010-2024

D health information is being requested: FIRST MIDDLE LAST MM Name: Date of Birth: DD / YYYY / Address: Social Security #: Telephone #: Email Address: 2. I authorize the release of the following information (check all applicable): â–  All records â–  HIV/AIDS â–  Inpatient medical records â–  Medication records â–  Outpatient medical records â–  Psychotherapy/psychiatric care records â–  Laboratory/pathology records â–  X-ray/radiology records â–  Drug and/or alcohol use record.

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  • HIV
  • x-ray
  • NW
  • requester
  • revocation
  • inpatient
  • Attn
  • discloses
  • ELIGIBILITY
  • applicable
  • psychotherapy
  • OUTPATIENT
  • revoke
  • disclosed
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