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ED MEDICAL INFORMATION Patient Name: Date of Birth: Telephone Number: I previously gave permission for the following physician(s) or organization(s) to access my electronic record for continuing care purposes, and I understand that this access may have already taken place: Physician/Organization Name(s): Physician/Organization Address: I now revoke this permission and DO NOT want the above named physician(s) or organization(s) to have access to my electronic medical record from this date fo.

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