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Get Tx The Medical Center Of Plano Gf-045 2011-2024

: Provider's Name: Recipient's Name: Social Security No. (optional): The Medical Center of Plano Provider's Address: 3901 W. 15th Street Address 1: Address 2: Plano, TX 75075 State: City: Phone: Zip: This authorization will expire on the following: (Fill in the Date or Event but not both.) Date: Event: Unless a shorter time period is specified, this authorization will expire 180 days after the date it is signed. Purpose of disclosure: Description of information to be used or disclosed.

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