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Er 42-09 28th Street, 12th Floor, CN-52 Queens, NY 11101-4132 If you do not want to be contacted, either by letter or by phone, regarding your A1C information and if you do not want your provider(s) to receive your A1C information from the NYC Department of Health and Mental Hygiene, please fill out this form. By submitting this form, you are requesting that (1) you are not contacted about your A1C information and (2) that your provider(s) not get your A1C information through the Department s.

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