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Limited Information

Medicare Beneficiary Services:1-800-MEDICARE (1-800-633-4227) TTY/ TDD:1-877-486-2048 This form is used to advise Medicare of the person or persons you have chosen to have access to your personal health Information .

Note: You have the right to take back (“revoke”) your authorization at any time, in writing, except to the extent that Medicare has already acted based on your permission.

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