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Release of Information

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What are they authorized to do?
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Reason for Release:
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I Understand, as the person signing this authorization:


I Understand, as the person signing this authorization:

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I will be given a copy of this authorization for my records and the original will be included in the healthcare record.
Please let parent, guardian, or your personal representative sign below:

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By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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