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Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Name (Last, First, MI) - Enter the patient's (recipient's) name as it appears on their Maryland Medical Assistance card. Print your last name, first name, and the first letter of your middle name. 2.
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