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Get Oasas - New York State

BUSE PATIENT M.I. CASE NO. FACILITY INSTRUCTIONS: FIRST UNIT GIVE A COPY OF THE FORM TO THE PATIENT! Prepare one (1) copy for the Patient's Case Record. If this form is sent to another agency with a request for information, prepare an additional copy for the Patient's Case Record. DISCLOSURE / RELEASE WITH PATIENT'S CONSENT (CIRCLE) EXTENT OR NATURE OF INFORMATION TO BE DISCLOSED/RELEASED I consent to the disclosure to and between the New York State Department of Health (DOH) and the.

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