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Get Only For The Purposes And

N to be used or disclosed: person or entity requesting the information and authorized to make the requested use or disclosure' Recipient of the information: This information is being requested for the following purpose(s): This auritorizatiolr shall remain in effect from the date signed below until (expiration date or event) I uncierstand that: .y I nray inspect or copy the protected health information It e to be used or disclosed above, attention I may revoke this authorization in writing.

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