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  • Authorization for Release of Medical Information

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  • I understand that:
    • My right to health care is not conditioned on this authorization.
    • I may cancel this authorization at any time by submitting a written request to the address at the top of this form, except where a disclosure has already been made in reliance on my prior authorization.
    • If the person or facility above receiving this information is not a health care or medical insurance provider covered by privacy regulations, the information stated above could be redisclosed.
    • There may be a charge for requested records.

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