• Permission to Release Private Health Information

  • I hereby authorize Alba Wellness Incorporated and its’ representatives to release my personal health information.

    This information will be released to:

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  • I am signing under the following conditions:

    • My judgment is not impaired by emotional duress or any chemicals
    • I may withdraw this authorization in writing at any time
    • If not withdrawn, this authorization expires in (12) twelve months


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  • Should be Empty: