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Get Pa Mr 543 2016-2024

___________________________________________________________________________________ Date of Birth: _____________________________________________ Phone: _______________________________________ THIS AUTHORIZATION WILL NOT BE ACCEPTED UNLESS ALL ITEMS ARE COMPLETED. The information being disclosed may include: HIV/AIDS, Drug/Alcohol Abuse & Mental Health data. This document authorizes release of information entered into my medical record prior to or within 12 months after the date of my signature. .

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