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I understand I may change or revoke this authorization at any time by providing written notice to Variety Care at: Variety Care, Attn: Medical Records, 6800 Broadway Extension, Oklahoma City, OK 73116. I understand I cannot restrict information that may have already been shared based on this authorization by a revocation or change.
By signing this request, the patient or representative acknowledges the following:
If you are not the Patient but you are signing on behalf of a patient, please complete this section:
You MUST attach proof of your authority to act on behalf of the patient as checked above (other than parent).