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Get Mental Health Assessment For General Relief YES - DPSS

SIGNATURE OF WITNESS PRINT NAME/ RELATIONSHIP TO PATIENT DATE Right to Revoke This Authorization I understand that I have the right to revoke this Authorization at any time by telling DPSS in writing. I may use the Revocation of Authorization at the bottom of this form. Mail or deliver the revocation to the following address: I also understand that a revocation will not affect the ability of DPSS or any health care provider to use or disclose the health information or.

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