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MACI N) Nombre Fecha de nacimiento Direcci n Ciudad Tel fono y c digo de larga distancia Estado C digo postal II. ALCANCE Y PROP SITO DE COMPARTIR LA INFORMACI N Entiendo que la informaci n de salud protegida es informaci n que me identifica. El prop sito de esta autorizaci n es el permitir a: que comparta mi informaci n m dica protegida. III. AUTORIZACI N E INFORMACI N A SER COMPARTIDA Yo autorizo a.

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